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SIXTH 

INTERNATIONAL  CONGRESS 

ON  TUBERCULOSIS 


IN   SIX   VOLUMES 
VOLUME    TWO 


PROCEEDINGS  OF  SECTION  m 
Surgery  and  Orthopedics 

PROCEEDINGS  OF  SECTION  IV 
Tuberculosis  in  Children 


WASHIN6T0N,  D.  C. 
SEPTEMBER  28  TO  OCTOBER  5,  1908 


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Transactions 

of  the 


Sixth  International  Congress 
on  Tuberculosis. 

WASHINGTON,  SEPTEMBER  28  TO  OCTOBER  5,  1908. 


WITH  AN  ACCOUNT  AND  CATALOGUE  OF  THE  TUBERCULOSIS 

EXHIBITION, 

WASHINGTON.  SEPTEMBER  21  TO  OCTOBER  12,  1908. 


3n  ^ix  Volumes!- 

VOLUME   TWO. 


PROCEEDINGS  OF  SECTION  III,         PROCEEDINGS  OF  SECTION  IF, 
Surgery  and  Orthopedics.  Tuberculosis  in  Infancy. 


Philadelphia : 

WILLIAM  F.  FELL  COMPANY 

1908. 


EDITED  BY  THE  SECRETARY-GENERAL. 


COMMITTEE  ON  PRINTING  AND  PUBLICATION. 

Dr.  Livingston  Farrand,  Chairman. 

Mr.  Homer  Folks. 

Dr.  H.  R.  M.  Landis. 

Dr.  John  H.  Lowman. 

Dr.  Marshall  L.  Price. 

Dr.  Joseph  Walsh. 

EDITORIAL  COMMITTEE. 

The  Presidents  of  the  Sections. 
Dr.  Wm.  H.  Welch. 
Dr.  Vincent  Y.  Bowditch. 
Dr.  Charles  H.  Mayo. 
Dr.  Abraham  Jacobi. 
Mr.  Edward  T.  Devine. 
Surgeon-General  Walter  Wyman. 
Dr.  Leonard  Pearson. 

EXECUTIVE  COMMITTEE. 

Dr.  Lawrence  F.  Flick. 
Dr.  Livingston  Farrand. 
Dr.  Joseph  Walsh. 
Dr.  John  S.  Fulton. 


Officers  of  Section  III. 


Presideni: 
Dr.  Charles  H.  Mayo. 

Honorary  Presidents: 
Dr.  Sydney  Stephenson,  London,      Prof.  Henri  Hartman,  Paris, 
Mr.  J.  H.  Stiles,  Edinburgh,  Dr.  R.  W.  Philip,  Edinburgh, 

Prof.  Sauerbruch,  Marburg,  Dr.  G.  Von  Illyes,  Budapest, 

Dr.  D.  A.  Codivilla,  Paris,  Mr.  Arbuthnot  Lane,  London, 

Dr.  A.  Jeanne,  Rouen,  Dr.  Nathan  Raw,  Liverpool, 

Dr.  Nov6  Josserand,  Lyon,  Dr.   Simon    Von  Unterberger,  St. 

Dr.  Wilhelm  Karo,  Berlin,  Petersburg, 

Baron  Takaka,  Tokyo. 


Dr.  Dudley  P.  Allen, 
Dr.  Arthur  D.  Bevan, 
Dr.  J.  A.  Blake, 
Dr.  Edward  H.  Bradford, 
Dr.  Joseph  D.  Bryant, 
Dr.  Wm.  T.  Bull,* 
Dr.  H.  L.  BuRRiLL, 
Dr.  Arthur  T.  Cabot, 
Dr.  W.  H.  Carmalt, 
Dr.  Wm.  E.  Casselberry, 
Dr.  J.  C.  Da  Costa, 
Dr.  D.  S.  Fairchild, 
Dr.  John  M.  T.  Finney, 
Dr.  Fred  H.  Gerrish, 
Dr.  A.  G.  Gerster, 
Dr.  Virgil  P.  Gibney, 
Dr.  William  S.  Halsted, 
Dr.  T.  W.  Huntington, 
Dr.  G.  Ben  Johnston, 
Dr.  W.  W.  Keen, 
Dr.  Howard  A.  Kelly, 
Dr.  Charles  McBurney, 
Dr.  H.  M.  McClanahan, 
Dr.  Andrew  J.  McCosh,* 
Dr.  K.  A.  J.  McKenzie, 
Dr.  Lewis  McMurtry, 


Dr.  Wm.  D.  Haggard, 


Vice-Presidents : 

Dr.  Rudolph  Matas, 
Dr.  Willy  Meyer, 
Dr.  John  B.  Murphy, 
Dr.  C.  B.  Nancrede, 
Surgeon-Gen.  R.  M.  O'Reilly, 
Dr.  Roswell  Park, 
Dr.  L.  S.  Pilcher, 
Dr.  J.  L.  Ransohoff, 
Dr.  M.  H.  Richardson, 
Surgeon-Gen.  P.  M.  Rixey, 
Dr.  Emmet  Rixford, 
Dr.  W.  L.  Rodman, 
Dr.  Nicholas  Senn,* 
Dr.  N.  M.  Shaffer, 
Dr.  George  E.  Shambaugh, 
Dr.  Lewis  A.  Stimson, 
Dr.  W.  B.  Van  Lennep, 
Dr.  G.  Tully  Vaughan, 
Dr.  S.  B.  Ward, 
Dr.  J.  Collins  Warren, 
Dr.  Stephen  H.  Weeks, 
Dr.  J.  William  White, 
Dr.  De  Forest  Willard, 
Dr.  H.  A.  Wilson, 
Dr.  George  B.  Wood, 
Dr.  John  A.  Wyeth, 
Dr.  Hugh  H.  Young. 

Secretaries: 

Dr.  John  T.  Bottomley. 
*  Deceased. 


Contents  of  Volume  II,  Section  III. 


Page 
President's  Address 1 

Dr.  Charle3  H.  Mayo. 

The  Construction  of  Hospitals  for  Tuberculous  Patients 5 

Mr.  Meyer  J.  Sturm. 

Tuberculosis  of  the  Larynx:     The  Type  which  is  capable  of  Recovery  or  "Arrest" 

and  the  Principles  of  Treatment 12 

Dr.  W.  E.  Casselberry. 

The  Ophthalmo-tuberculin  Test :     A  Note  on  its  Value  in  the  Question  of  Surgical 

Treatment  of  Orbital  Disease 26 

Dr.  Charles  A.  Oliver. 

Tuberculosis  of  the  Cornea 29 

Dr.  Oscar  Dodd. 

Tubercular  Disease  of  the  Middle  Ear 35 

Dr.  Clarence  J.  Blake. 

The  Surgical  Treatment  of  Tuberculous  Lesions  of  the  Upper  Respiratory  Tract.  .  .     40 

Dr.  D.  Braden  Kyle. 

Tuberculosis  of  the  Nose,  Mouth,  and  Pharynx 43 

Dr.  Harris  P.  Mosher. 

Tuberculosis  of  the  Cervical  Lymph  Nodes :  Report  on  275  Cases  treated  by  Radical 

Extirpation 54 

Dr.  Charles  N.  Dowd. 

Retroperitoneal  Tuberculous  Glands  and  their  Relation  to  Spinal  Symptoms 61 

Dr.  Charles  F.  Painter. 

Surgical  Aspects  of  Tuberculosis  of  the  Lung  and  Pleura 73 

Dr.  Samuel  Robinson. 

Die  chirurgische  Behandlung  der  Lungentuberkulose 82 

Prof.  F.  Sauerbruch. 

Tubercular  Arthritis  of  the  Hip-joint 100 

Dr.  S.  H.  Weeks. 

The  Treatment  of  Tuberculous  Hip  Disease  by  Weight  Bearing  and  Fixation  by  the 

Lorenz  Short-hip  Spica Ill 

Dr.  H.  a.  Wilson. 

Vaccine  Therapy  in  Joint  Tuberculosis 117 

Dr.  Edward  H.  Ochsneb. 

Deux  Formes  particulidres  d'arthropathies  tuberculeuses  du  genou 126 

Dr.  Madclaire. 

Immobilization  in  Tuberculous  Arthritis 129 

Dr.  a.  Codivilla. 
V 


VI  CONTENTS    OF    VOLUME    II,    SECTION    III. 

Page 
De  I'oblit^ration  des  cavit^s  osseusea  et  articulaires  tuberculeuses  avec  la  Pate  de 

Mosetig 140 

Dr.  Nov6-Jo8serand. 

The  Value  of  the  Roentgen  Method  in  the  Early  Recognition  of  Tuberculosis  of 

Bones  and  Joints 144 

Dr.  Carl  Beck. 

Treatment  of  Hip-joint  Disease 148 

Prof.  F.  Calot, 

Tuberculosis  of  the  Vas,  Epididymis,  and  Testis 149 

Dr.  .Toun  B.  Walker. 

Blasentuberkulose 157 

Dr.  Med.  Wilhelm  Karo 

Tuberculosis  of  the  Bladder 165 

Dr.  Bransford  Lewis. 

Tuberculosis  of  the  Kidney 176 

Dr.  Arthur  D.  Bevan. 

The  Surgical  Forms  of  Intestinal  Tuberculosis 183 

Dr.  Henry  Hartmann. 

Tuberculosis  of  the  Female  Generative  Organs 188 

Dr.  I.  S.  Stone. 

Tuberculosis  of  the  Peritoneum 189 

Dr.  F.  C.  Lund. 

Surgical  Bearings  of  Tuberculin 199 

Dr.  R.  W.  Philip. 

Tuberculosis  of  Bones  and  Joints 204 

Dr.  Edward  H.  Bradford. 

Open-air  and  Hyperemia  Treatment  as    Powerful  Aids  in  the    Management  of 

Complicated  Surgical  Tuberculosis  in  Adults 212 

Dr.  Willy  Meyer. 

The  Surgical  Treatment  of  Tuberculous  Sinuses  and  Their  Prevention 219 

Dr.  Emil  G.  Beck. 

How  the  State  of  Minnesota  cares  for  its  Indigent  Children  suffering  from  Tuberculo- 
sis of  the  Bones  and  Joints 251 

Dr.  Arthur  J.  Gillette. 

Open-air  Treatment  of  Surgical  Tuberculosis 257 

Dr.  Deforest  Willard. 

Tuberculosis  of  the  Urinary  Tract 268 

Dr.  Thoekild  Rovsino. 

Tuberculosis  of  Muscles,  Tendons,  and  Fascia 279 

Dr.  James  F.  Mitchell. 

Tuberculosis  of  the  Stomach,  Liver,  Gall-bladder,  and  Pancreas 289 

Dr.  L.  W.  Hotchkiss. 

La  cure  d'altitude  et  la  cure  solaire  de  la  tuberculose  chirurgicale 301 

Dr.  Rollibr. 

The  Acute  Forms  of  Abdominal  Tuberculosis 303 

Dr.  D.  N.  Eisendeath. 


CONTENTS    OF    VOLUME    II,    SECTION    III.  vii 

Page 
Rational  Spinal  Support 311 

Db.  Henry  W.  Frauenthal, 

tjber  die  Nierentuberkulose 315 

Dk.  G.  von  Illyes. 

tJber  Nierentuberkulose 318 

Dr.  B.  von  Rihmer. 

A  Study  on  Experimental  Tuberculosis  of  the  Testicle 323 

Dr.  Charles  Esmonet. 

Tuberculosis  of  the  Breast 346 

Dr.  William  L.  Hodman. 

Index 707 


Contents  of  Volume  II,  Section  IV. 


Page 

President's  Address 355 

Dr.  Abraham  Jacobi. 

Tuberculosis  in  Infants:     An  Analysis  of  131  Hospital  Cases  as  regards  Family- 
History  and  Physical  Signs,  with  Remarks  upon  Prevention  and  Treatment.  .   361 
Dr.  LinnjEus  Edford  La  Fetra. 

Tuberculosis  in  Children:  Particularly  with  Reference  to  Tuberculosis  of  Lymphatic 

Glands  and  its  Importance  in  the  Invasion  and  Dissemination  of  the  Disease.  .   367 
Dr.  Theodore  Shennan. 

The  Relation  of  Measles,  Whooping-cough,  and  Influenza  to  Tuberculosis  in  Child- 
hood     379 

Dr.  Edgar  P,  Copeland. 

On  von  Pirquet's  Cutaneous  Tuberculin  Test  on  Children  in  the  First  Year  of  Infancy.  385 

Prof.  O.  Medin. 

The  Opsonic  Content  of  Breast-milk 390 

Dr.  Wm.  J.  Butler. 

Report  of  a  Case  of  Miliary  Tuberculosis,  probably  of  Bovine  Origin,  in  a  Child,  aged 

Four  and  One-half  Months 394 

Dr.  E.  M.  Green  and  Dr.  A.  L.  Kotz. 

Clinical  Manifestations  of  Tuberculous  Meningitis 399 

De.  D.  J.  McCarthy  and  Dr.  C.  A.  Fife. 

The  Localization  of  Tuberculosis  in  Children 417 

Dr.  Woods  Hdtchinson. 

The  Distribution  of  Tuberculous  Lesions  in  Infants  and  Young  Children:  A  Study 

Based  upon  Post-mortem  Examinations 423 

Dr.  Martha  Wollstein. 

Tuberculous  Pulmonary  Cavities  in  Infants 434 

Dr.  C.  Y.  White  and  Dr.  H.  C.  Carpenter. 

The  Relative  Frequency  of  Abdominal  Tuberculosis  in  Childhood  in  Great  Britain 

and  the  United  States 446 

Dr.  David  Bovaird,  Jr. 

La  p^ritonite  tuberculeuse  du  nourrisson 454 

Prof.  M.  E.  Weill  and  Dr.  M.  Pine. 

Tuberculosis  of  the  Pericardium  in  Children 464 

Dr.  Joseph  S.  Wall. 

Des  albuminuries  intermittentes  de  I'enfance  consid^r^es  dans  leurs  relations  avec 

rh<5r6dit6   tuberculeuse 473 

Dr.  J.  Teissier. 

Children  of  the  Tuberculous 479 

De.  Theodore  B.  Sachs. 
ix 


X  CONTENTS    OF    VOLUME    II,    SECTION    IV. 

Page 
The  Occurrence  of  Pulmonary  Tuberculosis  in  the  Children  of  Tuberculous  Parents.   487 
Dr.  J.\me8  a.  Miller  and  Dr.  I.  Ogden  Woodruff 

A  Clinical  Study  of  the  Transmission  and  Progress  of  Tuberculosis  in  Children 

through  Family  Association 493 

Dr.  C.  Flotd  and  Dr.  H.  I.  Bowditch. 

Role  de  la  contagion  humaine  dans  la  tuberculose  infantile 503 

Dr.  J.  CoMBY. 

Obstructive  Abnormalities  of  the   Nose  and   Throat:    Predisposing   Factors  to 

Tuberculoeis  in  School  Children 515 

Dr.  John  J.  Cronin. 

The  Placental  Transmission  of  Tuberculosis 524 

Dr.  Aldked  S.  Warthin. 

De  I'air  confine  et  de  la  tuberculose 534 

M.  L'Architecte  Augustin  Rey. 

Higiene  Escolar  en  el  Ecuador 537 

Dr.  M.  Jigon  Bello. 

The  Value  and  Reliability  of  Calmette's  Ophthalmic  Reaction  to  Tuberculin 542 

Dr.  E.  Mather  Sill. 

The  Cutaneous  and  Ophthalmic  Tuberculin  Tests  in  Infants  under  Twelve  Months 

of  Age 547 

Dr.  Henry  L.  K.  Shaw. 

A  Report  upon  One  Thousand  Tuberculin  Tests  in  Young  Children 551 

Dr.  L.  E.  Holt. 

The  Frequency  of  Tuberculosis  in  Childhood 559 

Dr.  C.  von  Pirquet. 
Differential  Cutaneous  Reaction 568 

Dr.  Laislaw  Detre. 

Clinical  Observations  on  the  von  Pirquet  Reaction  in  Children 569 

Dr.  Henry  Heiman. 

Recent  Tests  in  the  Diagnosis  of  Tuberculosis  in  Children  at  the  New  York  Post- 

Graduate  Medical  School  and  Hospital 575 

Dr.  H.  D.  Chapin  and  Dr.  T.  H.  Coffin. 

An  Aid  to  the  Diagnosis  of  Tuberculosis  in  Infancy  and  Childhood  by  means  of  the 
Cutaneous  Inoculation  of  Diluted  Tuberculin  or  Pure   Tuberculin   (Pirquet 

Method) 581 

Dr.  Louis  Fischer. 

Diagnostic  Value  of  Lumbar  Puncture  in  Acute  Tuberculous  Meningitis  of  Children  588 

Dr.  F.  E.  Sondern. 

An  Expeditious  Method  for  the  Detection  of  Tuberculosis  among  School-children  .  .    598 

Dr.  Harlan  Shoemaker. 

Ein  Resolutions vorschlag 603 

Dr.  Adolf  Baumel. 

The  Value  of  Children's  Gardens  in  Congested  Neighborhoods  for  those  Children 
with  a  Tendency  to  Tuberculosis  or  for  those  in  whom  the  Disease  has  been 

Arrested  or  Cured 608 

Mrs.  Henry  G.  Parsons. 

The  Open-air  School 612 

Mrs.  Anna  Garlin  Spencer. 


CONTENTS   OF    VOLUME    II,    SECTION   IV.  XI 

Page 

Relation  of  Tuberculosis  to  Parks  and  Playgrounds 619 

Mb.  Howard  Bradstbebt. 

The  Hygienic  and  Climatic  Prophylaxis  of  Tuberculosis  in  Childhood 623 

Dr.  F.  L.  Wachenheim. 

Overcoming  the  Predisposition  to  Tuberculosis  and  the  Danger  from  Infection 

during  Childhood 635 

Dr.  S.  a.  Knopf. 

Oeuvre  de  la  preservation  de  I'enfance  contre  la  tuberculosa  Section  Lyonnaise.  .  .  .   648 

Dh.  Edmond  Weill. 

The  Prognosis  in  Pulmonary  Tuberculosis  in  Children  under  Fifteen  Years  of  Age.  .   652 

Dr.  P^ank  a.  Craig. 

Hygiene  of  the  Mouth,  Nares,  Pharynx,  Intestines,  Skin,  Mucous  Membrane  in 

General  Lymph  Bodies,  Lungs;  The  Prevention  of  Colds 671 

Dr.  Noble  P.  Barnes. 

The   Expectant   Treatment    of   Pulmonary   Tuberculosis — A    Contribution   from 

Orthopedic  Surgery 676 

Dr.  a.  B.  Jodbon. 

The  Seashore  and  Fresh-air  Treatment  at  Sea  Breeze  Hospital 682 

Dr.  J,  W.  Bbannan. 

The  Possibility  of  Avoiding  Conspicuous  Scar  Formation  in  Softened  Tuberculosis 

of  the  Cervical  Glands 703 

Dr.  Willy  Meter. 

Index 711 


SECTION  III. 
Surgery  and  Orthopedics. 


FIRST  DAY. 

Monday,  September  28,  1908. 

PRESIDENT'S  ADDRESS.  HOSPITAL  CONSTRUCTION.  TUBER- 
CULOSIS OF  THE  LARYNX.  OPHTHALMO-REACTION  IN  OPH- 
THALMIC SURGERY.  CORNEAL  TUBERCULOSIS.  TUBERCU- 
LOSIS OF  THE  MIDDLE  EAR.  SURGERY  OF  TUBERCULOSIS 
OF  UPPER  RESPIRATORY  TRACT.  TUBERCULOSIS  OF  NOSE, 
MOUTH,  AND  PHARYNX. 


The  Section  was  called  to  order  by  the  President,  Dr.  Charles  H.  Mayo, 
at  half  past  two  o'clock.  Honorary  Presidents  of  the  Section  were  elected 
as  follows: 

Mr.  Sydney  Stephenson,  London  Dr.  G.  von  Illyes,  Budapest 

Prof.  Sauerbruch,  Marburg  Mr.  Arbuthnot  Lane,  London 

Dr.  D.  A.  Codivilla,  Bologna  Dr.  Nathan  Raw,  Liverpool 

Dr.  Nove-Josserand,  Lyons  Mr.  J.  H.  Stiles,  Edinburgh 

Dr.  A.  Jeanne,  Rouen  Dr.    Simon    von    Unterberger,    St. 

Dr.  Wilhelm  Karo,  Berlin  Petersburg 

Dr.  Henri  Hartmann,  Paris  Baron  Takaka,  Tokyo 

Dr.  R.  W.  Philip,  Edinburgh 

Before  taking  up  the  formal  program  the  President  addressed  the  Section 
as  follows: 


PRESIDENT'S  ADDRESS. 

By  Charles  H.  Mayo,  A.M.,  M.D., 

Rochester,  Minn. 


I  am  deeply  conscious  of  the  importance  of  my  privilege  in  addressing  an 
audience  composed  of  those  who  are  associated  in  the  work  of  this  great 
International  Congress  on  Tuberculosis.  In  accepting  the  appointment  as 
president  of  the  Surgical  Section,  I  not  only  assumed  responsibility  for 
the  success  of  the  Section,  but  I  enlisted  in  a  common  cause  with  the  pro- 

VOL.  11 — 1  1 


2  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

fessional  men  of  all  nations  who  are  striving  to  suppress,  or  at  least  to 
alleviate,  the  suffering  caused  by  this  most  dreadful  of  scourges,  tubercu- 
losis. 

The  general  public  still  look  upon  the  disease  as  one  affecting  the  lungs, 
knowing  but  little  of  its  varied  manifestations.  As  men  representing  the 
surgical  methods  in  the  treatment  of  disease,  and  dealing  with  localized 
tuberculosis,  it  devolves  upon  us  to  consider  it  from  the  preventive,  preserva- 
tive, and  reconstructive  standpoint. 

Tuberculosis  is  a  disease  wliich  affects  the  majority  of  civilized  people  at 
some  time  during  their  lives.  As  but  10  per  cent,  of  the  population  die  of  it, 
we  have  a  right  to  say  that  few  serious  diseases,  not  self-limited,  tend  more 
naturally  to  ultimate  recovery  than  does  tuberculosis.  It  is  this  tendency 
which  renders  it  so  much  more  favorable  than  malignant  disease,  that  those 
afflicted  may  be  comforted  with  that  greatest  of  all  human  blessings — hope. 
In  fact,  the  disease  of  itself  seldom  destroys  life,  except  through  the  effects 
of  mixed  infections.  Tuberculosis  of  the  meninges  may  prove  fatal  without 
the  aid  of  other  germs;  and  yet  advances  in  brain  surgery  show  that  it  may 
be  possible  to  give  relief  even  in  this  condition. 

It  is  most  unfortunate  that  tuberculosis  is  so  prone  to  affect  the  young 
and  the  middle-aged,  during  the  productive  period  of  life.  For  an  adult  to 
become  dependent  upon  sympathy  or  aid  of  any  kind — be  it  medicine, 
crutch,  or  unearned  money — is  a  serious  matter.  To  be  physically  sick  is 
bad  enough,  but  is  not  to  be  compared  with  that  lamentable  condition — 
the  mental  disability  of  the  chronic  invalid. 

While  medicine  is  a  science,  in  many  particulars  it  cannot  be  exact, 
so  baffling  are  the  varying  results  of  varying  conditions  of  human  life. 
There  is  still  much  discussion  in  the  profession,  as  well  as  among  the  laity, 
as  to  the  manner  in  which  the  infection  enters  the  body — whether  through 
the  skin,  or  the  respiratory  or  alimentary  tract — and  how  long  it  may  lie 
dormant  before  manifesting  its  usual  signs.  Some  distinguished  investiga- 
tors have  encouraged  the  public  to  disregard  the  danger  of  infection  from 
animals.  One  might  say,  in  a  general  way,  that  it  would  be  better  to  con- 
sider several  sources  of  infection  as  possible  (which  is  our  present  belief) 
than  to  neglect  any  of  the  accepted  preventive  measures;  since  at  best  it  is 
a  difficult  matter  to  attain  high  standards  of  practical  hygiene. 

Infections  of  all  kinds  develop  toxins  peculiar  to  themselves  which  cause 
the  blood  to  produce  anti-bodies.  It  is  by  means  of  this  reaction  of  the 
blood  against  toxin  that  we  secure  our  varied  vaccines.  Many  individuals 
have  a  high  resistance  against  tuberculous  infection;  there  are  many,  how- 
ever, in  whom  the  blood  fails  to  develop  the  reaction  which  would  cause  the 
tubercle  bacilli  to  be  destroyed,  thrown  off,  or  even  walled  in,  as  usually 
occurs  in  common  infections. 


president's   address. — MAYO.  3 

While  we  review  the  various  methods  of  treatment  which  represent  our 
heritage  from  the  past  for  the  so-called  "cure"  of  tuberculosis,  it  is  well  that 
our  attention  should  be  directed  to  the  future,  with  its  sanguine  hope.  The 
failures  of  the  past  have  fulfilled  their  mission  in  the  progress  of  investigation, 
and  possibly  we  should  not  call  them  failures. 

The  disease  is  many-sided.  Medicine  still  holds  first  place  in  its  treat- 
ment, but  more  and  more,  as  time  passes,  the  physician's  plan  of  treatment 
in  cases  of  tuberculosis  includes  various  directions,  which  mean  nothing 
more  than  the  observance  of  simple  methods  of  correct  living.  We  are 
witnessing  extensive  experimentation  in  the  endeavor  to  develop  a  higher 
resistance  to  the  disease.  In  the  animal  world  the  results  are  extremely 
gratifying. 

Serum-therapy  is  again  claiming  wide  attention,  notwithstanding  its 
many  failures  in  the  past;  while  the  use  of  filtrates  and  attenuated  living 
tubercle  bacilli  have  many  advocates  who  report  success.  In  certain  forms 
of  joint  tuberculosis,  these  serums  and  vaccines  have  a  distinct  value. 
Their  use  offers  no  difficulty,  and  they  are  at  least  more  promising  than  the 
various  non-specific  injections  which  are  used  in  the  hope  of  developing 
better  repair  than  can  be  accomplished  by  the  patient  unaided,  or  aided 
only  by  general  hygienic  treatment. 

Surgeons  have  learned  that  pure  tuberculous  accumulations  must  not  be 
removed  without  great  care  to  prevent  mixed  infection.  By  many  failures, 
we  have  learned  that  it  may  be  harmful  to  operate  on  local  tuberculosis 
during  the  acute  fever  of  recent  infections,  and  that  the  treatment  along 
general  lines  must  make  good  progress  before  repair  by  surgery  can  be 
expected.  Through  failure  to  recognize  such  unfavorable  conditions,  ill- 
timed  operation  often  results  in  a  rapidly  disseminating  general  tuber- 
culosis. 

So  each  plan  of  treatment  has  its  application  in  some  type  of  tuberculosis, 
though  the  seeming  strife  among  the  advocates  of  various  methods  leads  the 
public  to  beUeve  that  we  are  disagreeing  among  ourselves.  The  ability  to 
consider  all  the  circumstances,  and  select  the  best  method  of  treatment  for 
the  individual  patient,  and  the  tact  and  skill  with  which  the  treatment  is 
carried  out,  determine  the  results  of  surgical  intervention,  and,  according 
to  these  results,  surgeons  are  graded. 

In  these  days  we  are  admitting  the  general  public  to  share  fully  in  all 
we  know  about  tuberculosis,  and  this  publicity  has  developed  a  strong 
sentiment  which  will  improve  our  legislation  on  foods,  especially  meat  and 
milk,  and  will  strengthen  other  sanitary  legislation.  The  era  of  a  national 
bureau  of  public  health  is  now  approaching.  Publicity  on  this  subject  has 
brought  about  improvements  in  the  care  of  sleeping  cars,  has  greatly  dim- 
inished the  evil  of  expectoration  in  public  places,  and  has  extended  to  the 


4  SIXTH  INTERNATIONAL  CONGRESS  ON  TUBERCULOSIS. 

farm,  where  serious  efforts  are  made  to  exterminate  and  to  prevent  tuber- 
culosis among  animals.  In  some  communities  a  morbid  fear  of  the  consump- 
tive has  arisen,  and,  while  this  adds  to  the  burdens  of  affliction,  it  is,  perhaps, 
unavoidable;  it  will  pass  away  in  time,  and,  on  the  whole,  it  is  undoubtedly 
for  the  public  good,  tending  toward  the  ultimate  control  of  the  disease. 


THE  CONSTRUCTION  OF  HOSPITALS  FOR  TUBER- 
CULOUS PATIENTS. 

By  Meyer  J.  Sturm,  B.S., 

Chicago,  III. 


Hospitals  for  surgical  tuberculosis  are  in  general  the  same  in  construction 
and  maintenance  of  the  buildings  as  hospitals  for  general  surgical  cases. 

The  special  features  of  construction  and  equipment  of  such  hospitals 
must  be  given  attention,  inasmuch  as  heretofore  nothing  along  this  line  has 
been  done  to  any  appreciable  extent  except  in  hospitals  which  have  been 
erected  for  general  surgical  and  medical  purposes,  where  makeshifts  were 
employed  to  bring  about  as  nearly  an  ideal  condition  as  was  possible  under 
the  circumstances. 

The  general  conditions  pertaining  to  the  construction  and  maintenance 
of  hospitals  for  the  treatment  of  tuberculous  cases,  whether  these  are  in 
surgical  tuberculosis  or  in  medical  tuberculosis,  are  the  same;  namely,  that 
there  should  be  sufficient  air  and  sunlight,  nourishing  diet,  and  the  facilities 
for  tranquillity  of  mind  and  an  abundance  of  rest. 

These  can  be  obtained  practically  in  the  ordinary  manner,  except  that 
provision  should  be  made  for  a  maximum  supply  of  fresh  air  at  all  times 
and  the  admission  of  a  flood  of  sunlight.  This  would  in  no  way  interfere 
with  the  incorporation  of  the  special  features  v;hich  are  necessary.  The 
locations  of  such  hospitals  should  be  chosen  with  this  in  view.  The  special 
features  may  be  summarized  as  follows: 

1.  An  abundance  of  sunlight. 

2.  Absence  of  noise, 

3.  Absence  of  dust. 

4.  Absence  of  smoke. 

5.  Proper  ventilation. 

6.  Disposition  of  sewage. 

7.  Safety  from  fire. 

8.  Possibility  of  future  expansion. 

9.  Accessibility  for  patients,  their  friends,  and  for  the  medical  staff. 
The  general  principles  which  apply  to  the  planning  and  construction  of 

all  hospitals  apply  equally  well  to  those  for  surgical  tuberculosis;   namely, 

5 


6  SIXTH    INTERNATIONAL  CONGRESS   ON   TUBERCULOSIS. 

first,  that  there  should  be  compactness;  second,  a  maximum  of  specific 
requirements  of  construction  with  the  least  cost;  and,  third,  the  maximum 
efficiency  of  maintenance  with  the  least  possible  cost,  so  as  to  benefit  the 
greatest  number  with  the  least  expenditure. 

The  first  can  be  obtained  by  building  superimposed  stories,  so  that  all 
plumbing,  wiring,  and  heating,  as  well  as  the  constructive  parts  of  the  hospi- 
tal, can  be  installed  in  the  simplest  forms.  This  will  give  the  required  com- 
pactness for  efficiency,  ease,  and  economy  of  maintenance. 

The  outline  laid  before  you  here  is  admirably  adapted  to  the  country 
branch  hospital,  which  is  coming  so  much  into  vogue,  but  this  paper  is  written 
with  the  fact  in  mind  that  in  most  cases  of  surgical  tuberculosis  it  is  those 
who  have  not  the  means  who  require  treatment  most  frequently;  and  if 
such  hospitals  were  built  within  easy  traveling  distance  from  the  homes  of 
these  people,  they  would  sei-ve  their  purpose  to  much  better  advantage, 
because  the  relatives  of  those  who  are  being  treated  can  much  more  readily 
keep  in  touch  with  the  patients.  This  is  often  the  deciding  factor  where 
such  persons  go  to  the  hospital  for  treatment. 

jMoreover,  this  is  practically  unavoidable,  because  it  is  necessary  to  make 
a  close  study  of  family  life,  for,  as  Dr.  Taylor  so  ably  says,  "The  hospital 
work  itself  cannot  be  conducted  intelligently  without  some  knowledge  of 
home  conditions  in  each  case."  There  should  be  an  out-patient  department, 
so  that  those  who  have  gone  from  the  hospital  when  they  are  able  to  do  so, 
and  who  still  need  treatment,  can  get  this  treatment  readily. 

In  the  planning  of  such  hospitals  large  windows  must  be  provided,  pref- 
erably of  the  Dutch  door  type  or  of  the  French  window  type,  so  that  beds 
can  be  moved  from  the  room  into  the  air.  It  is  not  possible  to  have  porches 
entirely  surrounding  the  building,  because  such  porches,  owing  to  the  width 
which  would  be  necessaiy  in  order  to  place  beds  upon  them,  would  cut  off 
entirely  the  sunlight  from  the  rooms;  and,  moreover,  such  an  extent  of  porch 
would  be  neither  an  economy  nor  a  necessity. 

An  arrangement  should  be  made  whereby  one  very  large  window  would 
be  left  free  to  admit  the  sunlight,  so  that  the  patient  could  be  moved  into  a 
sheltered  part  of  the  room,  and  these  porches  should  then  be  made  common 
to  two  rooms  on  another  window  or  door  from  each  of  these  rooms  respec- 
tively. These  porches  should  be  artistic  in  design,  and  form  an  integral 
part  of  the  general  architectural  scheme;  in  other  words,  they  should  be 
ornamental  as  well  as  useful. 

The  best  form  of  plan  for  such  buildings  is  to  place  at  the  south  large 
sun-parlors  which  have  direct  access  upon  special  solariums  in  the  form  of 
large  porches.  These  hospitals  could  be  planned  either  in  the  simple 
form  or  straightway  plan,  in  L-shape  or  U -shape  form,  and  this  idea  readily 
embodied. 


CONSTRUCTION   OF   HOSPITALS   FOR   TUBERCULOSIS. — STURM.  7 

If  a  straight  plan  be  used  with  the  rooms  or  wards  on  the  right  and  left 
of  a  corridor  running  north  and  south,  giving  all  rooms  either  east  or  west 
sunUght,  the  porches  on  both  these  sides  will  receive  the  morning  and  after- 
noon sun  respectively  in  the  same  manner  as  the  rooms  to  east  and  west. 

To  the  north  and  south,  especially  the  latter,  these  solariums  should  be 
placed;  those  at  the  north  need  not  be  as  large  as  those  at  the  south.  The 
south  porch  should  lead  directly  from  the  large  sun-parlor  on  each  floor 
through  French  windows.  This  sun-parlor  can  well  be  made  the  entire 
width  of  the  building  on  each  floor,  so  that  it  will  receive  sunlight  practically 
all  day.  There  should  be  large  windows  to  the  east  and  west  in  this  room, 
as  v.'ell  as  to  the  south.  All  these  windows  should  be  qf  such  pattern  that 
the  entire  room  can  be  made  practically  open,  and  be  screened  for  summer 
use. 

If  the  hospital  be  designed  in  the  L-shaped  plan,  this  would  apply  as 
well,  but  instead  of  having  the  sun-porches  on  the  north  and  south  wing 
only,  additional  porches  should  be  placed  on  the  east  and  west  wing  facing 
south,  unless  the  building  be  at  such  an  angle  that  the  porches  face  south- 
east and  southwest. 

In  the  U-shaped  hospital  the  parallel  wings  should  have  sun-porches 
precisely  like  those  in  the  straight  plan  hospitals,  with  the  addition  of  those 
in  the  large  court  between  the  two  wings. 

The  building  should  be  equipped  with  large  elevators  running  from  the 
basement  continuously  through  to  the  level  of  the  roof,  of  sufficient  size  and 
capacity  to  carry  one  or  even  two  beds,  so  that  the  beds  can  be  taken  to 
the  roof.  All  doors  in  the  hospital  should  be  made  sufficiently  wide  to  per- 
mit the  moving  in  and  out  of  beds. 

In  designing  hospitals  along  these  lines,  this  has  been  quite  successful, 
especially  where  part  of  the  roof  has  been  equipped  with  gas-pipe  standards 
and  horizontal  bars,  so  that  an  awning  could  be  stretched  over  part  of  the 
roof,  for  the  protection  of  the  patients  from  the  direct  rays  of  the  sun  on  hot 
days,  and  also  that  there  may  be  no  inconvenience  to  patients  during  in- 
clement weather. 

A  division  should  be  made  on  such  a  roof  by  erecting  either  a  canvas 
partition  or  a  partition  of  other  material,  about  six  feet  in  height,  leaving  a 
space  of  a  foot  or  eighteen  inches  at  the  bottom,  so  that  the  male  and  female 
patients  can  be  separated. 

Large  canvas  reclining  chairs  and  benches  should  be  put  on  the  roof. 
There  should  also  be  running  filtered  water.  Fully  equipped  toilet-rooms 
and  a  service  room,  with  space  and  equipment  for  the  bed-pans  and  other 
paraphernalia  required,  should  be  provided,  just  as  they  are  on  the  floor  of 
an  ordinar}'  hospital.  Besides  this  general  equipment,  there  should  be 
placed  in  this  service  room  a  blanket  warmer.    There  should  be  good  stout 


8  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

canvas  screens  with  heavy  bases,  so  they  cannot  be  blown  over.  These 
screens  should  be  placed  on  rollers,  so  that  they  can  readily  be  put  around 
a  bed  in  cases  where  the  semces  of  a  nurse  are  required. 

Cots  and  beds,  where  it  is  possible,  should  be  left  on  the  roof  or  on  the 
special  balconies  winter  and  summer.  Where  this  is  not  expedient,  the 
open  window  into  the  room  is  admirable. 

The  first  floor  shall  be  elevated  above  the  grade,  so  as  to  get  light  into 
the  basement,  but  the  elevator  is  to  have  a  landing  stage  on  the  level  of  the 
ground,  so  that  wheel-carts  and  w^heel-stretchers,  and  for  that  matter  beds, 
can  be  run  out  upon  the  lawns. 

In  addition  to  the  stairways,  there  should  be  a  gradual  incline  or  run- 
way from  floor  to  floor,  so  that  wheel-chairs  and  wheel-stretchers  can  be 
readily  taken  up  and  down  these,  or,  in  cases  where  it  is  possible,  the 
patients  can  wheel  themselves  from  floor  to  floor  and  in  and  out  of  the 
building. 

The  hospital  itself  must  be  so  constructed  that,  while  a  patient  is  under 
surgical  or  mechanical  treatment,  the  windows  can  be  kept  open  continually, 
these  windows  to  be  of  the  tj^pe  which  can  be  either  raised  or  lowered  and 
swung  out  at  an  angle,  much  as  an  av/ning  would  be  swung  out,  so  that 
they  could  be  kept  open  continually. 

This  type  of  window  is  operated  much  like  a  transom,  except  that  it  can 
be  lowered  into  grooves,  so  that  in  its  natural  position  it  runs  hke  an  ordinary 
window,  and  can  be  raised  and  lowered  as  such. 

Dr.  Taylor  says,  in  referring  to  this,  that  "the  patients  should  be  pro- 
vided with  hoods,  wrappers,  comforters,  and  screens,  and  that  the  windows 
should  be  kept  continually  open.  The  nurses  should  wear  sweaters,  and  the 
temperature  of  the  rooms  in  cool  months  should  not  rise  above  60°  in  the 
daytime  and  50°  at  night;  they  should  preferably  be  much  colder." 

All  such  hospitals  are  necessarily  to  be  constructed  fireproof,  and  their 
equipment  is  to  contain,  besides  the  special  apparatus  for  the  treatment  of 
tuberculous  cases,  the  special  sterilizers  for  bed-pans,  urinal  cans,  and  small 
and  large  cuspidors  on  each  floor  and  in  roof  service  rooms. 

The  toilet  and  service  rooms  are  to  be  separated;  that  is  to  say,  the 
bathing  facilities  and  water-closets  are  not  to  be  in  the  same  room  as  the 
slop-hoppers,  slop-sink,  bed-pan  sterilizers,  and  the  special  bed-pan  racks, 
broom  closet,  and  preparation  table,  which  are  to  be  provided  in  each  such 
room. 

These  rooms  are  to  be  placed  on  either  side  of  a  shaft  running  the  full 
depth  of  both  of  the  rooms,  making  the  space  between  the  two  rooms  about 
three  feet.  By  doing  this  a  continuous  duct  is  formed  for  the  reception  of 
all  the  plumbing  pipes  and  wires,  which  are  in  this  way  easily  accessible,  and 
also  will  make  room  for  from  two  to  four  spacious  ventilating  ducts,  which 


CONSTRUCTION   OF   HOSPITALS   FOR  TUBERCULOSIS. — STURM.  9 

can  be  operated  merely  by  putting  a  gas-burner  or  a  small  radiator  at  the 
foot  of  each  duct,  and  running  these  ducts  continuously  from  basement  to 
six  to  ten  feet  above  the  roof,  with  a  hood  to  keep  out  rain  over  each.  Forced 
ventilation  can  be  installed  to  operate  these  ducts. 

In  the  equipment  of  bath-rooms  all  tubs  are  to  stand  free,  so  that  the  nurse 
can  walk  entirely  around  the  tubs.  The  tubs  should  be  solid  to  the  floor,  with 
no  space  underneath.  Water-closets  are  to  be  fastened  to  the  wall  and  free 
from  the  floor.  Provision  is  to  be  made  for  portable  tub  service,  namely, 
the  water-supplies  and  waste  necessaiy  for  this  t^^e  of  tub.  The  lavatories 
or  sinks,  so  far  as  possible,  if  put  into  the  toilet-room,  are  to  be  placed  on 
brackets,  and  the  supplies  run  to  the  walls.  These  lavatories  should  invari- 
ably take  the  form  of  a  sink  into  which  can  be  placed  separate  wash-basins, 
so  that  these  basins  can  be  kept  clean  and  sterile,  racks  or  hooks  being 
provided  for  hanging  these  basins  over  the  lavatories. 

The  equipment  of  the  main  Idtchen,  wliich  is  to  be  placed  on  the  top 
floor,  is  the  same  as  that  for  kitchens  in  general  hospitals.  In  each  of  the 
special  and  ordinary  diet-kitchens  there  is  to  be  a  large  table  w^th  racks 
under  for  the  reception  and  setting  up  of  the  food  trays.  There  uill  be  in 
each  such  diet-kitchen  a  small  steam  table  with  a  combination  gas-stove, 
the  entire  base  of  this  steam  table  being  a  plate-warmer. 

Instead  of  having  the  dishes  washed  in  each  diet-ldtchen,  there  is  to  be 
a  fully  equipped  dish-washing  room,  preferably  in  the  basement,  connected 
with  all  diet-kitchens  and  main  kitchens  by  a  food-lift  and  small  dumb- 
waiter. This  room  is  to  contain  at  least  two  sinks  for  the  washing  of  egg- 
cups  and  such  dishes  as  have  to  be  washed  by  hand,  and  two  small  sinks  for 
the  washing  and  rinsing  of  glassware,  and  a  mechanical  dish-washer  in  which 
the  dishes  are  washed  and  cleaned  by  boiling  water  and  live  steam. 

If,  in  a  six-story  hospital,  there  is  one  special  diet  and  a  general  Idtchen, 
besides  the  diet-kitchens  on  each  floor,  instead  of  having  the  crews  necessary 
to  do  the  dish-washing  in  each  kitchen,  one  crew  or  possibly  two  can  do  the 
washing  for  the  entire  institution,  and  the  dishes  can  be  distributed  very 
easily  with  this  arrangement. 

By  placing  the  kitchen  on  the  top  floor  and  equipping  tliis,  as  well  as  the 
diet-kitchens,  as  described,  it  is  possible  to  serve  all  food  hot  and  palatable 
at  all  times.  The  added  advantage  of  having  the  kitchen  on  the  top  floor  is 
the  fact  that  it  can  be  more  adequately  ventilated  and  lighted  than  it  can 
in  any  other  location  in  the  building.  This  eliminates  the  attendant  odors 
entirely  from  the  hospital,  as  they  naturally  arise  even  with  the  best  ventilat- 
ing systems,  for  during  the  warmer  months  the  windows  are  open  in  both 
kitchen  and  rooms  above  the  kitchen,  and  thus  the  odors  permeate  the  entire 
building. 

There  are  to  be  suflScient  private  rooms  in  all  such  hospitals,  depending 


10  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

upon  the  size  of  the  institution,  and  the  scope  of  the  work,  and  the  demand 
for  such  rooms.  The  wards  are  all  to  be  small — preferably  from  four  to  six 
beds.  These  small  wards  are  especially  valuable  in  hospitals  connected 
with  medical  schools,  as  one  or  more  of  these  wards  can  be  regularly  assigned 
to  senior  and  junior  students  for  a  definite  period  of  time. 

In  these  wards  the  patients  are  not  distributed,  because  there  can  be  a 
better  selection  of  cases,  namely,  acute  surgical  cases  can  all  be  placed  in 
small  wards,'while  those  who  are  convalescing  will  not  be  disturbed,  because 
they  are  placed  in  other  small  wards.  Moreover,  if  there  is  a  preponderance 
of  male  patients  over  female  patients,  or  vice  versa,  there  is  more  elasticity 
in  the  small  ward,  owing  to  the  fact  that  if  there  is  only  one  male  or  one 
female  patient,  and  a  great  number  of  female  or  male  patients  respectively, 
an  entire  large  ward  need  not  be  given  over  to  this  one  patient,  whereas  the 
other  ward  would  be  crowded.  It  is  very  important  in  hospitals  to  have 
all  the  floors  so  arranged  that  each  floor  contains  only  private  rooms  or  only 
wards,  because  private  rooms  and  wards  on  the  same  floor  invariably  give 
rise  to  endless  annoyance. 

There  should  be  in  such  a  hospital  the  customary  electric  signal  system 
for  calling  nurses,  preferably  of  the  type  which  calls  by  electric  light  over 
the  doors,  this  being  positive  and  quiet  and  having  no  bells  which  are  con- 
tinually ringing  and  disturbing  patients.  It  has  been  found  to  be  the  most 
economical  of  all  systems  in  installation  and  operation,  as  it  takes  only  the 
ordinaiy  electric  light  circuit  with  the  special  relays,  with  pilot  lights  and 
extension  pilots. 

The  operating  department  is  practically  the  same  as  for  ordinary  hospitals 
in  plan  and  equipment,  and  is  to  be  placed  on  the  top  floor,  so  that  it  can  be 
well  lighted  and  ventilated,  and  so  that  the  noise  will  not  disturb  the  patients 
in  the  building. 

The  floors  in  such  a  hospital  should  be  of  one  of  the  monolithic  types 
now  on  the  market,  which  are  becoming  more  successful.  These  floors  are 
all  to  have  cove  bases. 

The  walls  and  ceilings  of  such  hospitals  should  have  cement  plaster  with 
slight  coves  at  all  angles,  as  a  matter  of  cleanliness  and  not  that  there  is  any 
danger  of  lodgment  of  germs.  All  these  walls  should  be  treated  with  a  so- 
lution and  given  two  or  three  coats  of  good  paint  or  enamel.  All  paints  to 
have  dull  finish,  to  be  obtained  in  the  paint  and  not  by  stippling. 

The  general  equipment,  such  as  vacuum-cleaning  systems,  which  are 
advocated  especially  in  hospitals  of  this  character,  as  well  as  the  general 
arrangement  aside  from  that  described,  is  practically  uniform  with  other 
classes  of  hospital  buildings. 


CONSTRUCTION   OF   HOSPITALS   FOR   TUBERCULOSIS. — STURM.  11 

DISCUSSION. 
Dr.  Francis  W.  Gallagher  (El  Paso,  Texas) :  It  would  be  better,  if 
possible,  to  have  separate  hospitals  for  surgical  tuberculosis,  and  in  such  an 
event  I  know  of  no  arrangement  which  would  more  fully  answer  the  require- 
ments than  the  detail  presented  to  the  Congress  by  Mr.  Sturm.  Private 
philanthropy  may  supply  such  institutions  in  two  or  three  of  the  largest 
centers  of  population,  but,  for  the  present  at  least,  the  tuberculosis  surgical 
cases  will  have  to  be  cared  for  in  institutions  devoted  to  the  tuberculous, 
or  else  in  the  surgical  wards  of  our  general  hospitals.  The  former  would  be 
the  preferable,  plan.  The  hospital,  as  distinguished  from  the  open-country 
sanatorium,  must  necessarily  be  so  constructed  as  to  accommodate  many 
patients  under  a  single  roof,  and  the  plan  proposed  by  Mr.  Sturm  utilizes, 
to  the  best  advantage,  the  roof  and  porch  room.  The  high  cost  of  ground 
space  makes  the  multiple  story  necessary,  and  a  building  too  far  from  the 
center  of  business  life  precludes  largely  the  attendance  of  the  doctors  more 
actively  engaged,  in  this  as  in  other  departments  of  professional  work,  and 
this  is  necessary  as  a  general  proposition  for  the  best  results.  There  can  be 
little  doubt  that  the  man  in  touch  with  the  world  of  medicine  outside  of  the 
hospital  would  exert  the  greatest  influence  for  good  within  the  hospital. 
All  other  things  being  equal,  there  can  be  no  doubt  of  the  superior  advantage 
of  the  open-country  sanatorium,  and  this  situated  away  from  contaminating 
influences  of  the  city,  and  in  a  climate  where  the  air  is  largely  germ-free 
and  low  in  humidity,  and  with  other  conditions  which  permit  living  out  of 
doors  day  and  night. 


TUBERCULOSIS  OF  THE  LARYNX: 

THE  TYPE  WHICH  IS  CAPABLE  OF  RECOVERY  OR  "ARREST," 
AND  THE  PRINCIPLES  OF  TREATMENT. 

By  W.  E.  Casselberry,  M.D., 

Professor  Emeritus  of  Laryngology    and    Rhinology    in    Northwestern  University  Medical  School, 

Chicago. 


I.  The  Non-resistant  Type. — On  the  principle  that  an  overpower- 
ing though  often  erroneous  impression  is  produced  by  tragic  events,  our 
common  conception  of  tuberculosis  of  the  larynx  is  drawn  from  its  harrowing 
course  in  about  two-fifths  of  the  cases  which,  collectively,  for  contrast,  I 
designate  the  non-resistant  type,  and  which  is  characterized  by  a  speedy 
development,  persistent  progress,  and  rapidly  fatal  termination.  Out  of  a 
total  of  60  cases  of  private  record,  these  qualities  pertained  to  a  group  of 
24,  or  40  per  cent.,  in  all  of  whom  death  ensued  in  less  than  an  average  of 
one  year  from  first  observation,  and  in  less  than  two  years  from  the  first- 
remembered  symptom  of  the  laryngeal  complication.  A  classical  laryngeal 
image  of  the  disease  is  presented  in  Fig.  1,  sketched  from  nature  in  the  person 
of  one  of  this  group. 

It  will  not,  therefore,  seem  inappropriate,  as  the  argument  proceeds, 
that  tuberculosis  of  the  larynx  which  has  proved  capable  of  healing  or 
"arrest"  should  be  designated  as  a  type,  for,  while  Heryng,  ICrause,  and  Lake 
have  dwelt  upon  its  surgical  curability  in  isolated  instances,  I  seek  to  establish 
for  laryngeal  tuberculosis  what  is  now  well  known  with  respect  to  the  pul- 
monary affection,  the  fact  that,  in  certain  patients,  nature  develops  an 
adequate  resistance,  self-sufficient  to  "arrest"  the  disease,  and  that  in  certain 
other  patients  nature  develops  an  almost  but  not  quite  adequate  resistance, 
which,  when  persistently  reinforced  by  the  best  methods  of  our  art,  then 
suffices  to  arrest  the  disease. 

II.  The  Hopefully  Resistant  Type. — Twenty-two  in  number,  or 
two-fifths  of  the  total  series,  compose  a  second  group  in  which  the  laryngeal 
tulierculosis  ran  a  much  slower  course,  the  natural  resistance  of  the  patient 
having  been  sufficient  to  effect  temporary  amelioration  and  arrest,  but 
usually  in  the  end  having  fallen  short  of  permanent  arrest.  Of  this  number, 
8  are  accurately  known  to  have  succumbed,  but  only  after  from  three  to 
seven  years,  and   12,  when  last  observed,  were  obviously  doomed,  also 

12 


Fig.  1. — A  classical  image  of  tuberculosis  of  the  larj'nx.     Miss  A.  C.     Non-resistant  type. 


Fig.  2. — Clironic  hyperplastic  tuberculosis  of  the  larj-nx  of  five  years'  duration. 
Mr.  E.  Z.  Hopefully  resistant  type,  now  in  the  eighth  year,  and  almost  but  not  quite 
"arrested." 


Fig.  o. — Tuberculosis  of  the  laryn.x.     Case  of  .Mr.  R.  A.  L.  nine  years  ago. 
for  eight  years  past  in  a  state  of  "arrest." 


Now  and 


LARYNGEAL  TUBERCULOSIS: — THE    CURABLE   TYPE, — CASSELBERRY.        13 

Tiaving  sui-vived  through  their  own  inherent  resistance,  with  but  desultory 
aid,  for  from  three  to  seven  years.  This  brings  the  mortaUty  of  the  entire 
series  to  80  per  cent.;  but  the  cloud  is  not  without  its  silver  lining,  for,  in 
addition  to  the  third  group,  that  of  permanent  arrests  which  will  take  up 
the  other  20  per  cent.,  there  remain  two  cases  of  this  second  group  which, 
by  aid  of  modern  methods  and  suitable  habits  of  life,  have  now  almost,  if 
not  quite,  reached  a  state  of  permanent  arrest.  The  condition  of  the  larynx 
in  one  of  these  as  sketched  at  its  worst,  nearly  three  years  ago,  is  shown 
in  Fig,  2,  in  which,  bearing  upon  the  diagnosis,  it  should  be  observed  by 
comparison  that,  aside  from  a  unilateral  predominance,  the  lesions  are 
identical  in  kind  with  those  in  Fig.  1,  which  in  turn  was  selected  from 
the  non-resistant  type  to  represent  the  classical  aspect  of  tuberculosis  of 
the  larynx. 

The  pyriform  swelling  of  the  arytenoid  is  the  same  in  kind,  although 
greater  in  degree;  it  blends  in  like  manner  with  another  swelling  of  the  inter- 
arytenoid  fold,  and  blends  also  with  a  diffused  hyperplasia  of  the  ventricular 
band.  In  the  angle  formed  by  the  attachment  of  the  posterior  end  of  the 
left  vocal  cord  there  is  the  same  sort  of  flexion  fissure  with  eroded  surface, 
from  which  sprout  equally  characteristic  granulomata.  The  patient,  Mr. 
E.  Z.,  then  aged  forty-four,  had  first  noticed,  five  and  a  half  years  previously, 
a  persistent  cough  with  expectoration,  which  was  followed  in  four  months 
by  a  hemorrhage,  and  within  two  years  by  laryngeal  pain  on  swallowing. 
His  well-nourished  appearance,  to  quote  the  patient's  own  phrase,  "  seemed 
to  belie  his  disease,"  and  this,  together  with  the  unilateral  predominance 
of  the  lesions  in  the  larynx,  which,  however,  I  have  observed  in  the  propor- 
tion of  1  to  15,  suggested  unusual  care  in  the  diagnosis.  The  apex  of  the 
right  lung  gave  signs  of  a  hmited  tuberculous  deposit.  Bacilli  were  "  pres- 
ent, a  few  to  a  field";  histological  guinea-pig  test  was  positive.  Also,  the 
tuberculin  test  was  positive.  Weight,  131  pounds,  representing  a  loss  of 
8  pounds;  pulse,  80  to  100;  temperature,  97°  to  99°  F.  Under  treatment 
at  the  end  of  a  year  (the  sixth  year  of  the  disease)  the  laryngeal  hyperplasia 
had  diminished;  the  granulomatous  fissure  had  become  merely  an  irregular 
crease  in  a  somewhat  redundant  tissue;  the  voice  resumed  fair  service,  and 
the  pain  on  swallowing  had  faded  to  a  vague  sense  of  "something  there," 
and  with  a  gain  of  16  pounds,  his  ratio  of  weight  to  height  was  in  excess. 
At  present,  in  the  eighth  year  of  the  disease,  although  the  larj^ngeal  hyper- 
plasia is  still  evident,  its  inactivity,  as  judged  by  the  lapse  of  time,  with 
absence  of  ulceration  and  freedom  from  pain  or  irritation,  indicates  a  state 
of  retrogression  approaching,  but  not  yet  to  be  classed  quite  as,  a  permanent 
"arrest." 

III.  Successfully  Resistant  Type  or  Type  Capable  of  Arrest, — 
A  third  group  is  composed  of  1 1  cases,  or  nearly  20  per  cent,  of  the  series, 


14  SIXTH    INTERNATIONAL  CONGRESS   ON   TUBERCULOSIS. 

in  which  the  laryngeal  tuberculous  lesions  are  or  were  in  a  state  of  arrest 
after  the  lapse  of  periods  varying  from  four  to  fourteen  years.  It  is  not 
meant  that  all  of  them  recovered  permanently  from  every  phase  of  tuber- 
culosis, for  the  very  fact  that  at  length  some  of  them  have  died  of  tuberculosis 
of  the  lungs  or  other  organs  will  be  cited  in  evidence  that  the  laryngeal 
complication,  during  its  course,  was  of  the  same  nature;  but  it  is  meant  by 
the  term  "arrest,"  that  for  a  number  of  years  all  progression  in  the  larynx 
has  been  interrupted  and  retrogression  established,  as  indicated  by  the 
cicatrization  of  the  ulcers,  if  any,  the  gradual  lessening  of  hyperplasia,  and 
the  cessation  of  subjective  pain  and  irritation.  In  order  to  be  fully  credited, 
an  allegation  of  recovery  or  even  "arrest"  from  laryngeal  tuberculosis  must 
be  supported  in  a  manner  to  overcome  both  a  natural  contention  of  possi- 
bility of  error  in  diagnosis  and  an  innate  doubt  of  the  permanence  of  such 
an  "arrest,"  for  it  is  true  that  sjqahilis  of  the  larynx  or  other  tractable  con- 
dition is  liable,  exceptionally,  to  be  mistaken  for  or  to  coexist  with  tuber- 
culosis, and  true,  also,  that  no  period  of  years  is  an  absolute  guarantee 
against  recurrence.  Therefore  the  pertinent  features  of  the  cases  of  this 
group  will  be  summarized  in  a  manner  designed  to  render  competent  the 
evidence,  when  taken  as  a  whole,  even  though  the  future  should  alter  the 
logic  of  events  with  respect  to  certain  of  the  details. 

Four  of  the  patients  have  been  under  my  own  inspection  at  various 
periods  both  before  and  after  the  "arrest."  Persons  of  this  type  are  able 
to  travel  far  and  wide,  so  that  when  information  at  first  hand,  based  on  the 
recorded  results  of  competent  examination  of  the  larynx  by  one  and  the 
same  observer  both  before  and  after  "arrest"  is  available,  and  is  reasonably 
conclusive  in  detail,  it  should  go  far  toward  satisfying  any  doubt  of  the 
existence  in  reality  of  a  tuberculosis  of  the  larynx  originally,  and  toward 
justifying  the  use  of  the  term  "  arrest"  as  a  description  in  truth  of  the  present 
state.  It  so  happens,  however,  that  two  of  them — the  two  perhaps  of  most 
importance — have  also  been  examined  both  during  and  after  the  "arrest" 
by  Dr.  Gildea,  of  Colorado  Springs,  whose  reports  cover  the  intervening 
periods  and  bring  the  records  up  to  date. 

No  one  would  doubt  the  tuberculous  nature  of  the  laryngeal  lesions  in 
the  first  of  these,  which  I  will  illustrate  in  Fig.  3  as  sketched  from  nature 
in  January,  1901.  The  mammillated  hyperplasia  of  the  interarytenoid 
fold,  the  granulomatous  proliferation  around  the  vocal  process,  the  flexion 
fissure  at  the  angle  of  junction  of  the  cord  and  arytenoid,  the  mouse-nibbled 
ulceration  about  the  fissure,  and  the  pyriform  swelling  of  the  arytenoids, 
form  together  a  picture  which  is  absolutely  characteristic  of  the  disease. 
It  concerned  the  Rev.  J.  W.  D.,  who  was  then  twenty-seven  years  of  age, 
having  had  pulmonary  tuberculosis  previously  for  three  years,  and  the  laryn- 
geal complication  for  about  one  year.     He  proved  suitable  for  surgical  treat- 


Fig.  3. — Case  of  tlie  Rev.  J.  \V.  D.  eight  years  ago.  Tuberculosis  of  the  larynx 
in  its  second  year.  Now  and  for  five  and  one-half  years  in  a  state  of  "arrest,"  as  shown 
in  the  next  figure. 


Fig.  4. — Ca.se  of  the  Rev.  J. 


W.  D.     Now  in  a  state  of  "arrest,"  and  showing  a  smooth 
scar.     Compare  with  Fig.  3. 


LARYNGEAL  TUBERCULOSIS: — THE    CURABLE   TYPE — CASSELBERRY.        15 

ment,  and  received  seven  thorough  excisions  or  curettements,  one  each  month, 
supplemented  by  lactic  acid  frictions  running  up  to  90  per  cent,  in  strength. 
It  is  specifically  recorded  of  the  fourth  curettement  that  it  was  directed  to 
the  remains  of  the  fissure  and  adjoining  ulceration,  and  again  recorded,  at 
the  completion  of  the  local  treatment,  that  the  granulomatous  hyperplasia 
had  been  mostly  removed,  and  that  all  broken  and  ulcerated  surfaces  were 
healed.  Of  course,  some  deeply  seated  infiltration  remained,  but  even  its 
retrogression  dates  from  this  treatment,  at  the  conclusion  of  which  a  change 
of  climate  to  the  Rocky  Mountain  region  favored  the  improvement,  which 
went  steadily  on.  A  year  later  Dr.  Gildea  reported:  "All  activity  in  his 
throat  has  ceased."  "Voice  fairly  clear."  At  the  end  of  six  years  Mr.  D. 
himself  reported:  "The  larynx  has  been  well  for  four  years."  "  Voice  fairly 
strong."  Now,  at  the  end  of  eight  years.  Dr.  Gildea  again  reports:  "Al- 
though much  fibrosis  in  the  lungs  and  a  few  tubercle  bacilli  are  found,  the 
larynx  is  absolutely  well,  the  voice  being  clear  and  good  and  the  arytenoids 
normal,"  and  Dr.  Gildea  has  made  a  sketch  of  the  larynx,  which  I  reproduce 
in  Fig.  4,  exhibiting  the  present  smooth,  pearly-white,  and  healed  appearance 
of  the  same  site  which  is  shown  in  the  previous  figure  to  have  been  so  char- 
acteristically tuberculous  eight  years  ago.  A  comparison  of  the  two  pictures 
demonstrates  that  not  merely  an  "arrest,"  but  an  actual  recovery,  so  far 
as  concerns  his  tuberculosis  in  the  larynx,  has  taken  place.    To  recapitulate: 

The  time  from  the  beginning  of  the  pulmonary  tuberculosis  is  eleven 
years. 

The  time  from  the  beginning  of  the  laryngeal  tuberculosis  is  nine  years. 

The  duration  of  "arrest"  of  the  laryngeal  tuberculosis,  with  the  patient 
living  at  this  date,  is  five  and  a  half  years. 

Equally  characteristic  are  the  tuberculous  lesions  depicted  in  Fig.  5, 
as  sketched  from  nature  in  the  person  of  Mr.  R.  A.  L.  in  February,  1900. 
Again,  the  granulomatous  infiltration  centers  about  the  vocal  process  or 
point  of  junction  of  the  vocal  cord  with  the  arytenoid,  which  is  a  favorite 
site  in  the  larynx  for  the  initial  infiltration.  A  similar  flexion  fissure  is  seen 
to  be  forming  in  the  pyriform  swelling  of  the  ar^^enoid,  but  it  is  as  yet  with- 
out definite  ulceration.  The  conspicuous  infiltration  of  the  right  side  of  the 
epiglottis  is  shown  as  embracing  also  the  pharyngo-epiglottic  fold,  and  dotted 
under  its  surface,  having  been  plainly  visible  in  the  image,  more  so  than  in 
the  illustration,  were  many  individual  tubercles.  By  reason  of  this  condition 
of  the  epiglottis,  which  already  caused  pain  in  swallowing,  I  then  regarded 
the  prognosis  as  unfavorable,  although  in  other  respects  it  was  hopeful.  He 
was  then  thirty-nine  years  of  age,  having  had  slowly  developing  apical 
pulmonary  tuberculosis  for  six  years,  and  the  laryngeal  complication  for 
one  year,  the  bacilli  present  being  few  in  number.  Weight,  155;  pulse,  120. 
His  local  treatment,  by  curettement  and  lactic  acid,  I  directed  especially  to 


16  SIXTH    INTERNATIONAL  CONGRESS   ON  TUBERCULOSIS. 

the  granulomatous  focus  around  the  vocal  process,  which  improved  under 
it.  The  change  of  climate  after  some  months  was  first  to  the  Rocky  Moun- 
tain region,  and  on  his  return  in  January,  1901,  I  was  quite  surprised  to 
observe  that  the  laryngeal  infiltration  had  disappeared,  a  fact  which  I  find 
recorded  in  these  words:  "Infiltration  of  epiglottis  not  now  discernible,  and 
no  pain  whatever  in  swallowing.  Weight,  196;  pulse  still  120;  lungs  in 
statu  quo."  At  my  third  and  fourth  observations,  in  August,  1901  and 
1902,  the  larynx  remained  equally  well  and  the  lungs  had  improved.  He 
lived  next  in  southern  California,  whence  Dr.  Radebon,  in  1907,  reported 
him  as  living  in  good  health,  and  being  now  in  Colorado  again.  Dr.  Gildea 
reports  that  his  larynx  remains  well.     To  summarize: 

The  time  from  the  beginning  of  the  pulmonary  tuberculosis  is  fourteen 
years. 

The  time  from  the  Beginning  of  the  laryngeal  tuberculosis  is  nine  years. 

The  duration  of  the  "arrest"  of  the  laryngeal  tuberculosis  is  eight  years, 
and  he  is  living  at  this  date. 

I\Ir.  P.,  aged  forty-five  in  1901,  had  diffused  infiltration  of  two  years' 
duration  at  favorite  sites  in  the  larynx,  but  without  definite  ulceration; 
copious  expectoration  with  many  tubercle  bacilli,  evident  pulmonary  signs, 
and  a  positive  tuberculin  reaction.  The  absence  of  a  corresponding  degree 
of  emaciation  led  to  particular  care  in  diagnosis.  He  was  made  a  test 
case  for  the  a;-ray  treatment,  which,  although  it  failed  in  subsequent  cases, 
seemed  decidedly  beneficial  to  him,  and  he  received  within  six  months  no 
less  than  48  exposures,  after  which,  on  special  examination  for  the  purpose, 
I  recorded:  "Larynx  undoubtedly  better,  but  not  well.  Infiltration  much 
less;  voice  improved — his  friends  commenting  on  it."  During  the  next  eight 
months  he  received  only  fresh-air  treatment,  after  which  was  noted,  "  con- 
tinued reduction  of  the  hyperplasia,"  and  after  two  years,  on  examination, 
his  lar}'ngeal  tuberculosis  I  recorded  as  "arrested,"  "with  only  residual 
hj-perplasia  remaining."  At  the  end  of  seven  years  he  writes  from  Iowa, 
where  he  has  reentered  employment,  saying,  "I  have  further  improved, 
only  slight  hoarseness  and  occasional  coughing  remain."     To  recapitulate: 

The  time  from  the  beginning  of  the  laryngeal  tuberculosis  is  nine  years. 

The  duration  of  the  "arrest"  is  five  years,  and  he  is  living  at  this 
date. 

Mr.  W.,  aged  twenty-three  in  1893,  had  typically  tuberculous  laryngeal 
infiltration  of  the  left  vocal  process  and  adjoining  parts  of  the  arytenoid 
angle  and  fold,  of  six  months'  duration,  dating  from  vocal  impairment,  and 
had  also  tuberculous  cei-vical  adenitis  and  evident  pulmonary  disease. 

Business  requirements  caused  his  treatment  for  several  months  to  be 
limited  to  antiseptic  and  emollient  local  applications,  but  afterward  he 
changed  to  an  outside  occupation  in  the  far  West.     On  his  return,  five  years 


LARYNGEAL  TUBERCULOSIS: — THE    CURABLE   TYPE. — CASSELBERRY.        17 

later,  the  larynx  showed  a  mere  residuum  of  the  former  tuberculous  infiltra- 
tion, and  up  to  the  end  of  seven  years  he  had  remained  well.     Recapitulating: 

The  time  from  the  beginning  of  the  laiyngeal  tuberculosis  up  to  the 
period  of  last  information  is  eight  years. 

The  unknowTi  duration  of  the  "arrest"  is  five  years,  and  he  is  probably 
hving  at  this  date. 

In  Cases  V  and  VI  the  condition  before  the  "arrest"  is  known  through 
examination  by  the  author,  but  the  opinion  that  an  "arrest"  of  the  tuber- 
culous process  in  the  larynx  has  since  occurred,  is  necessarily  based  on  written 
reports  by  the  patients,  stating  that  they  are  now,  after  many  years,  living 
and  subjectively  well  with  respect  to  the  larynx. 

Mr.  P.  P.  was  sent  to  Saranac  Sanitarium  in  1901,  whence  Dr.  Fremley 
transmits  a  copy  of  the  record,  which  not  only  confirms  the  diagnosis,  but 
indicates  that  his  tuberculosis  of  the  larynx  grew  worse  for  some  months, 
the  epiglottis  and  arytenoid  being  described  as  considerably  enlarged,  the 
infiltration  previously  having  been  limited  to  the  vocal  processes  and  inter- 
ai'}i;enoid  fold.  He  received  tuberculin  R  in  minute  doses,  but  the  "  arrest" 
culminated  only  after  subsequent  prolonged  open-air  living  in  the  West. 

The  time  since  the  beginning  of  the  laryngeal  tuberculosis  is  nine  years. 

The  duration  of  the  "  arrest"  is  seven  3^ears,  and  he  is  living  at  this  date. 

Mrs.  O.  P.  A.  resorted  at  once  to  the  open  life  by  removal  to  the  West, 
receiving  no  other  treatment.  The  infiltration  had  been  distinct,  but 
limited  to  the  vocal  cords.     She  reports  annually. 

The  duration  of  the  " arrest"  is  four  years,  and  she  is  living  at  this  date. 

In  the  next  group  of  five  cases  the  evidence  is  complete  with  reference  to 
the  final  "arrest,"  but  not  quite  so  respecting  the  first  diagnosis,  the  author's 
observations  having  been  limited  to  the  periods  after  the  arrest;  but  I  was 
able  to  observe  the  residual  hyperplasia  and  a  few  small  scars  and  depressions 
in  the  tissue  left  by  the  ulceration.  None  of  them  ever  suffered  any  relapse 
in  the  larynx,  but  they  died  of  the  underlying  pulmonary  tuberculosis  at 
the  length  of  four,  five,  nine,  ten,  and  eleven  years,  respectively,  after  an 
"arrest"  of  the  laryngeal  complication  had  taken  place,  its  date  having 
been  fixed  by  the  cessation  of  symptoms  and  the  statements  of  former 
physicians,  some  of  whom  were  able  to  certify  also  to  the  original  diagnosis. 
The  only  doubt  would  concern  the  possible  coexistence  of  syphilis  in  the 
larynx,  a  combination  which  would  be  unusual  in  so  large  a  proportion  of 
cases.  An  additional  case  is  purposely  excluded,  although  tuberculous  in 
the  larynx  and  lungs,  for  the  reason  that  the  breadth  of  scar  tissue  and  its 
site  at  the  borders  of  the  epiglottis  did  suggest  a  possible  coexisting  syphilis, 
notwithstanding  the  history  and  physical  signs  were  those  of  tuberculosis. 
It  is  obvious,  therefore,  that  I  have  not  been  unmindful  of  the  fact,  recently 
stated  anew  by  Griinwald,  that  "Confusion  with  tertiary  ulceration,  and 
still  more  with  syphilitic  infiltration  and  perichondritis,  is  to  be  feared,  even 


18  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

hemorrhage  being  not  rarely  an  early  symptom  of  the  tertiary  infiltration 
of  the  mucous  membranes,"  but  I  believe  this  ancient  error  has  not  been 
permitted  to  vitiate  the  value  of  this  group  of  "arrests." 

Mr.  B.,  examined  in  1895,  the  laryngeal  disease  being  then  of  two  years' 
duration,  and  already  in  a  state  approaching  arrest.  There  was  residual 
interarytenoid  hyperplasia  and  cicatricial  indentation  of  one  cord,  represent- 
ing a  loss  of  substance  from  ulceration,  which  had  healed.  He  had  already 
regained  his  voice,  and  was  able  thereafter,  for  nine  years,  to  use  it  as 
teacher  in  a  school  of  acting. 

The  time  from  the  beginning  of  the  pulmonary  tuberculosis  was  eleven 
years.  The  duration  of  the  "arrest"  of  the  larjmgeal  tuberculosis  was 
nine  years  to  date  of  death. 

Mr.  Fred  B.,  of  Texas,  when  examined  in  1893,  had  infiltration  of  the 
arytenoids  and  fold,  the  disease  being  then  in  a  state  approaching  arrest. 
His  son,  answering  my  inquiry,  states  that  the  throat  remained  well  until 
death  ensued  from  tuberculosis  of  the  bladder,  seven  years  afterward. 

The  duration  of  the  "arrest"  was  seven  years  to  date  of  death. 

Mr.  C,  examined  in  1894,  had  multiple  small  cicatricial  indentations  of 
one  ventricular  band,  the  ulcers  having  healed.  No  recurrence  in  the  larynx 
during  a  period  of  five  years,  up  to  the  time  of  his  demise  from  an  acute 
relapse  of  an  old-standing  evident  pulmonary  tuberculosis.  Verification  by 
Dr.  Staples,  of  Dubuque,  who  had  persistently  treated  the  lar}Tigeal  ulcer- 
ations with  menthol  in  olive  oil  during  two  years  until  they  were  healed. 

The  duration  of  the  "arrest"  was  five  years  to  date  of  death. 

In  1891,  while  on  a  visit  in  New  Mexico,  I  examined  Mr.  S.,  an  active 
business  man,  whose  sallow  complexion  and  sepulchral  voice  had  attracted 
my  notice,  and  who  was  pointed  out  to  me  as  a  marvelous  climatic  recovery, 
then  of  eleven  years'  standing,  from  laryngopulmonary  tuberculosis.  The 
examination,  which  he  courteously  permitted,  left  no  doubt  that  the  still 
perceptible  but  healed  distortion  of  the  larynx  represented  a  former  tuber- 
culosis in  a  state  of  "arrest."  He  died  some  years  later,  but  without  having 
suffered  any  recurrence  in  the  larynx. 

The  duration  of  the  "arrest"  was  at  least  fifteen  years  to  date  of  death. 

]\Iiss  W.  exhibited  at  first  only  a  pair  of  typical  "singers'  nodes,"  doubt- 
less due  to  forcing  the  voice  in  kindergarten  work,  during  that  period  of 
enfeeblement  of  the  lar}Tix  which  is  common  to  initial  tuberculosis,  inasmuch 
as  six  months  later  there  was  present  a  characteristic  tuberculous  h}T3er- 
plasia  of  the  ventricular  band,  a  pyriform  swelling  of  one  arytenoid,  and  pain 
on  swallowing.  But  at  this  stage,  notwithstanding  the  disease  in  the  lungs 
subsequently  progressed  to  a  fatal  issue  within  five  years,  all  further  develop- 
ment in  the  larynx  ceased  under  the  influence  of  a  year's  life  in  the  open 
air,  and  retrogression  took  place  to  the  degi'ee  that  all  subjective  symptoms 
referable  to  the  larynx  subsided  permanently. 

The  duration  of  the  "arrest"  was  four  years  to  the  date  of  death. 

Local  Treatment. — ^The  treatment  of  tuberculosis  of  the  larynx  is  a 
chapter  of  deep  gloom  in  medicine,  and  its  surgical  treatment  after  two 
decades  of  indiscriminate  application  stands  to-day  in  little  better  repute ; 
but  the  foregoing  analysis  shows  that  the  prognosis  is  not  so  absolutely  bad, 


LARYNGEAL  TUBERCULOSIS: — THE    CURABLE   TYPE. CASSELBERRY.        19 

and  it  indicates  that  if  the  malady  be  early  recognized  in  all  its  seriousness, 
and  persistently  but  wisely  managed  with  respect  to  the  type,  the  results 
will  be  far  better.  To  paraphrase  a  previous  statement,  so  general  is  our 
misconception,  based  on  the  rapidly  fatal  course  in  the  non-resistant  type 
(two-fifths),  that  I  was  myself  surprised  and  encouraged  on  counting  up  as 
many  as  20  per  cent,  of  recoveries  or  "arrests"  (one-fifth),  aside  from  the 
many  others  of  an  inherently  hopeful  type  (two-fifths). 

Intralaryngeal  surgical  treatments  were  made  in  several,  but  particularly 
in  the  two  indubitable  cases  depicted  in  Figs.  3-5,  in  each  of  which  an  "ar- 
rest" with  retrogression  followed  to  a  degree  most  striking  and  complete. 
The  treatments  consisted  of  excision  of  circumscribed  infiltrations  by  punch 
forceps,  and  of  sharp  curettage  of  granulomatous  and  ulcerated  areas,  methods 
which  require  special  skill  and  selection  of  cases,  but  which,  in  the  resistant 
types,  for  lesions  which  are  reasonably  accessible  and  not  too  diffused  nor 
too  deeply  seated,  are  capable,  in  isolated  instances,  of  inaugurating  recovery 
or  prolonging  hfe.  Likewise  the  abscission  of  a  tuberculous  epiglottis  is  a 
beneficent  measure,  if  only  for  the  removal  of  an  agonizing  impediment  to 
the  swallo-^dng  of  food.  On  the  other  hand,  to  attempt  any  of  these  methods 
in  patients  of  the  non-resistant  type  is  but  to  court  opprobrium  and  to  invite 
disaster. 

Although  the  type  be  suitable,  lest  the  way  be  opened  to  mixed  in- 
fection and  disintegration  thereby  hastened,  one  should  hesitate  to  sever,  by 
operation,  a  previously  unbroken,  moderately  smooth  surface,  which  over- 
lies a  diffused  tuberculous  infiltration.  Such  a  condition,  for  instance,  as 
is  represented  in  Fig.  2,  in  which  I  refrained,  for  this  reason,  from  excising 
even  a  fragment  for  microscopical  examination.  However,  I  feel  little  hesi- 
tation in  primarily  breaking  through  a  gi'anulomatous,  vegetating  or  papil- 
lomatous surface  which  surmounts  a  moderately  circumscribed  infiltration. 

The  method  by  galvanocautery  deep  punctures  I  have  long  employed, 
but  usually  only  for  exceptional  reasons,  but  it  is  now  being  earnestly 
advocated  by  experienced  operators*  as  the  most  generally  applicable,  far- 
reaching,  and  efficient  of  minor  surgical  means.  In  two  patients  in  whom 
I  repeatedly  applied  it  with  thoroughness,  one  for  a  pronounced  interary- 
tenoid  infiltration  amounting  almost  to  a  tumor,  the  other  for  diffused 
hyperplasia,  the  escharotic  loss  of  substance  after  each  slough  had  separated, 
would  appear  itself  to  be  of  small  extent,  but  it  had  the  advantage  of  reaching 
deeply  into  the  infected  structures,  and  the  inflammatory  reactions,  although 
not  very  severe,  seemed  to  exert  an  absorbent  effect  on  the  tuberculous 
hyperplasia  throughout  an  area  extending  considerably  beyond  that  of  the 
actual  caustic  destruction.     Both  of  them  made  temporary  "arrests,"  but 

*Grilnwald,  "Die  Therapie  der  Kehlkopf  Tuberculosis,"  Lehmann's  Verlog, 
Munchen,  1907. 


20  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

subsequently  passed  from  my  observation,  hence  are  not  among  those  above 
enumerated  in  that  class. 

At  the  end  of  a  course  of  surgical  treatment,  whether  by  galvanocautery 
or  cutting  instruments,  it  should  be  realized  that  minor  areas  of  residual 
hyperplasia  will  still  remain,  and  some  deeply  seated  foci  of  infection  sur- 
vive, so  that  a  relapse  is  to  be  expected  unless  increased  resistance  is  culti- 
vated, preferably  by  life  in  the  open  air,  with  all  thereby  implied,  which, 
in  the  20  per  cent,  of  "arrests"  described,  exerted  a  powerful  curative 
influence. 

Lactic  acid,  10  to  90  per  cent.,  applied  by  cotton  friction,  and  creosote 
by  submucous  injection,  being  somewhat  escharotic  in  their  effects,  may  be 
classed  with  surgical  methods  as  requiring  discrimination  in  use.  Lactic 
acid  tends  to  heal  ulceration,  and  it  is  an  adjuvant  to  curettage,  a  practical 
individual  test  of  its  eflicacy  being  a  reasonable  toleration  of  the  painfulness 
of  its  application  and  a  prompt  amelioration  of  the  painfulness  of  the  disease. 
At  present,  formalin,  0.25  to  1  per  cent.,  preferably  by  a  deeply  reaching 
spray,  is  growing  to  replace  lactic  acid,  the  same  test  being  a  useful  guide  in 
its  use. 

Radical  External  Operations. — Griinwald*  collates  73  cases  operated 
upon  by  European  surgeons,  access  for  excision  of  the  diseased  parts  being 
in  most  of  them  made  by  laryngofissure,  of  which  75  per  cent,  had  died 
within  a  year  or  so  after  the  operation,  and  only  8  per  cent,  had  recovered 
and  remained  well  for  over  two  years.  Nevertheless,  in  this  small  number 
of  recoveries  were  several  brilliant  ones  in  which  the  patient's  general 
condition  having  been  still  good,  he  had  faced  death  from  suffocation 
or  inanition,  in  consequence  of  laryngeal  tumefaction,  perichondritis,  or 
ulceration.  Tuberculous  tumors,  in  conjunction  with  other  lesions,  pre- 
dominate in  this  Ust  of  recoveries  which  followed  external  operations.  Such, 
in  brief,  are  the  conditions  which,  in  my  opinion,  may  justify  an  external 
operation,  while  in  the  absence  of  urgent  laryngeal  symptoms  or  in  the  pres- 
ence of  advanced  lung  disease,  an  external  radical  operation  can  be  but 
rarely  indicated.  Impending  suffocation  in  the  presence  of  advanced  lung 
disease  is  appropriately  met  by  tracheotomy. 

Local  medical  treatment,  although  it  may  seem  to  have  exerted  but  a 
minor  effect  in  those  cases  in  which  the  tuberculous  process  in  the  larynx 
eventually  became  arrested,  nevertheless  is  always  helpful  and  sometimes  is 
indispensable. 

Formalin  and  lactic  acid  have  already  been  mentioned  as  adjuvants  to 
surgical  measures.  Also,  they  tend  to  promote  the  cicatrization  of  ulcers, 
perhaps  succeeding  brilliantly  or  again  failing  utterly,  but  they  have  little 
or  no  effect  on  unbroken  infiltrations,  and  as  their  primary  irritation  is  not 

*  Loc.  cit. 


LARYNGEAL  TUBERCULOSIS: — THE   CURABLE   TYPE. CASSELBERRY.       21 

well  tolerated  in  the  non-resistant  type,  it  is  well,  in  using  either  medicament, 
to  abide  by  the  test  of  its  efficacy  previously  given. 

A  mentholated  emollient  spray,  containing  menthol,  0.25,  the  oils  of 
eucalj'ptus  and  gaultheria,  each,  1.00,  in  yellow  vaselin  oil,  100.00,  is,  within 
limits,  a  sedative  to  cough  and  pain,  and  is  suitable  for  home  use.  To  it 
may  be  added,  to  exalt  its  sedative  effect,  the  uncombined  alkaloid  cocain, 
0.1  to  0.2,  previously  made  in  solution  with  olive  oil,  5.00  to  10.00,  the  pure 
alkaloid  being  selected  because  its  hydrochlorid  is  not  soluble  in  fixed  oils. 
For  severe  cough  and  pain  a  mixture  of  powdered  cocain  hydrochlorid  0.5, 
and  powdered  orthoform  100.00,  insufflated  in  the  dose  of  0.5  gm.  twice 
daily,  affords  the  greatest  relief,  provided  care  be  taken  that  the  insufflation 
reach  the  interior  of  the  larynx.  Cocain,  even  in  this  harmlessly  minute 
dose,  is  unrivaled  in  momentary  effectiveness,  but  alone  is  too  evanescent, 
while  the  sedation  by  orthoform  alone  is  too  mild  in  degree,  but  is  of  several 
hours'  duration.  To  the  mixture  of  the  two  may  be  added,  further,  codein 
sulphate,  0.5  to  the  100.00.  It  is  unfortunate  that  skilled  service  is  usually 
required  to  insufflate  the  larynx  effectively;  when  this  is  not  available  and 
self-insufflation  fails,  orthoform  in  egg-emulsion,  applied  by  means  of  a 
coarse  spray  or  a  syringe,  ranks  next,  but  is  troublesome  in  use,  so  I  usually 
substitute  for  it  the  mentholated  and  cocainized  oil  spray,  adding  orthoform 
each  time,  placed  in  suspension  by  shaking. 

Systemic  Treatment. — In  reading  before  the  Surgical  Section  of  the 
Congress,  it  was  convenient  to  consider  "Systemic  Treatment  in  General" 
consecutively  to  the  case  of  E.  Z.,  by  which  it  was  exemplified,  which  ac- 
counts for  the  following  somewhat  detached  but  still  pertinent  references  to 
that  case. 

Practical  experience  is  still  limited  with  the  treatment  of  laryngeal  cases 
by  tuberculin  in  the  minute  dose  of  yw^tj  milligram,  and  by  other  vaccines 
and  sera,  the  scientific  purpose  of  which  is  to  augment  resistance  as  measured 
preferably  by  the  opsonic  index,  but  it  presents  an  encouraging  outlook, 
and  in  the  few  cases  so  treated  under  my  obsei^vation  the  tuberculin  seemed 
helpful,  in  one  decidedly  so,  and  in  none  did  it  seem  in  any  way  detrimental. 

In  the  resistant  types,  the  three  cardinal  principles,  rest,  open-air  living, 
and  forced  feeding,  should  be  even  more  rigorously  enforced  than  in  lung 
disease  alone,  as  the  chance  for  life  is  less  hopeful.  By  "rest"  should  be 
understood  not  only  rest  of  the  body  and  mind,  but  rest  to  the  voice  and 
rest  from  the  exactions  of  business.  Rest  is  first  named  because  it  is  of 
first  importance,  compliance  with  the  other  two  cardinal  principles  being 
dependent  upon  it.  I  have  found  business  the  major  impecUment  to  home 
treatment.  It  takes  the  courage  of  conviction  to  advise  the  sacrifice  of  a 
man's  ambition,  to  say  naught  of  his  income,  and  yet  it  must  be  done,  or 
all  other  efforts,  being  deemed  subservient  to  business  stress,  become  but 


22  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

half-way  measures;  no  hours  are  kept,  and  no  advice  followed  excepting 
as  business  permits.  Referring  to  Mr.  E.  Z.,  he  was  advised  to  this  effect, 
he  made  the  sacrifice,  and  reaped  his  reward  in  restoration  to  health  and 
business  capacity.  Moreover,  rest  to  the  voice  is  so  essential  that  business 
dictations  must  be  strictly  enjoined,  and  even  social  conversation  should  be 
limited.  In  the  treatment  of  tuberculosis  of  any  other  joint,  as,  foi-  instance, 
the  knee  or  hip,  immobilization  is  quite  the  rule;  why  not  so  in  the  laiynx? 
It  is  good  management  at  critical  periods,  and  at  some  but  not  all  other 
times,  for  laiyngopulmonaiy  patients  to  remain  where  skilful  local  treatment 
is  available,  hence,  usually  at  or  near  their  home  city;  and  this  plan  becomes 
more  feasible  as  the  knowledge  spreads  that  it  is  fresh  air  rather  than  any 
particular  kind  of  fresh  air  which  is  required,  and  also  more  acceptable  to 
patients  since  the  inhospitable  legend,  "No  case  of  tuberculosis  received," 
is  now  so  commonly  found  posted  at  resorts.  Nevertheless,  in  the  20  per 
cent,  of  "arrests"  which  my  series  affords,  it  is  evident  that,  following  the 
completion,  for  a  time,  of  the  local  treatment,  a  powerful  curative  influence 
was  exerted  by  life  in  the  open  air,  and  as  this  mode  can  be  carried  out  with 
less  friction  amid  sunshine  and  dryness,  I  have  recommended,  at  suitaljle 
periods,  for  the  resistant  types,  a  resort  to  favorable  climates,  giving  prefer- 
ence to  localities  where,  when  needed,  a  continuation  of  local  treatment  is 
available,  for  by  means  of  it  the  oft-intensified  distress  of  the  patient  can  at 
least  be  greatly  ameliorated.  In  fact,  as  it  is  impracticable  in  the  long  run 
for  two  physicians  to  be  retained,  it  is  proper  to  lay  special  stress  in  this 
connection  upon  the  recommendation  that  as  soon  as  laryngeal  tuberculosis 
is  found  to  complicate  a  pulmonary  case,  the  treatment,  not  alone  of  the 
larynx,  but  of  the  disease  as  a  whole,  should  be  intrusted  to  one  who  is  skilled 
in  laryngeal  technic,  for  the  laryngeal  involvement  is  the  immediate  life- 
threatening  factor  in  the  case,  and  only  in  this  way  can  the  natural  resistance 
of  the  patient  be  conserved  and  the  general  management  of  this  especially 
desperate  combination,  laryngopulmonary  tuberculosis,  be  placed  in  line 
with  the  present  wide-spread  determination,  of  which  this  Congress  is  an 
exponent,  to  moderate  the  misery  and  mortality  of  the  great  white  plague. 
Referring  again  to  Mr.  E.  Z.,  he  secured  a  house  with  grounds  in  a  near-by 
suburb,  w^here  he  fitted  up  a  corner  sleeping  porch  on  which,  notwithstanding 
the  severity  of  the  winter  season  at  Chicago,  he  slept  out  every  night  through- 
out the  entire  year.  There  were  wild  nights  of  wind  and  storm,  but  such 
an  extreme  limit  of  night  exposure  was  rather  his  own  choice,  and  to  this 
extent  it  is  not  usually  to  be  commended.  Laryngopulmonary  patients 
of  the  non-resistant  type,  especially,  cannot  endure  inclement  night  exposure, 
as  in  them  it  tends,  by  aggravating  the  irritability  of  the  larynx,  to  increase 
the  pain  in  swallowing,  and  thus  to  cut  down  the  nourishment.  At  first, 
on  sleeping  out,  even  the  average  cold  at  night  and  the  early  morning  damp- 


LARYNGEAL  TUBERCULOSIS: — THE   CURABLE   TYPE. — CASSELBERRY.       23 

ness  quite  generally  excite  coughing  spells,  but  the  resistant  types  soon 
harden  to  a  reasonable  degree  of  cold,  beyond  which  point  discretion  is  the 
better  part  of  valor.     In  conclusion,  it  has  been  shown: 

1.  That  tuberculous  hyperplasia  in  the  larynx  has  not  infrequently 
undergone  resolution  in  the  whole  or  in  part. 

2.  That  unmistakable  tuberculous  ulcers  have  occasionally  healed  and 
remained  healed. 

3.  That  favorable  negative  qualities  have  characterized  in  common  the 
cases  which  have  proved  to  be  capable  of  "  arrest"  or  recovery;  for  instance, 
the  laryngeal  hyperplasia  has  been  less  progressive,  less  diffused,  and  less 
prone  to  ulceration;  the  underlying  pulmonary  infection  has  been  less 
extended;  there  were  fewer  tubercle  bacilli,  a  lower  pulse-rate,  and  less 
emaciation. 

4.  That,  these  qualities  persisting,  the  cases  which  are  capable,  at  least, 
of  a  hopeful  resistance,  can  be  differentiated,  thus  justifying  every  effort 
at  any  sacrifice  to  invoke  the  methods  likely  to  arrest  the  disease  and  lead 
to  recoveiy,  including  intralaryngeal  surgery  when  the  lesions  in  degree  and 
kind  are  suitable  for  it. 

5.  That,  in  like  manner,  the  non-resistant  type  should  be  recognized, 
and  those  patients  guarded  from  the  privation  and  distress  which  surely 
follow  in  the  wake  of  an  indiscriminate  exposure  to  the  elements  and  to  the 
hardships  of  travel  in  distant  climes.  In  them  surgery  is  contraindicated, 
excepting  to  prevent  air-hunger  and  suffocation  or  to  prevent  starvation 
by  the  removal  of  some  particularly  painful  impediment  in  swallowing. 


Tuberculosis  de  la  Laringe:  Cases  Capaces  de  Recuperar. — (Casselberry.) 

Se  busca  establecer  en  la  tuberculosis  de  la  laringe,  lo  mismo  que  se 
dice  existir  en  la  tuberculosis  pulmonar:  esto  es  el  desarrollo  de  la  resis- 
tencia  natural,  capaz  de  detener  el  proceso  de  la  enfermedad;  tambidn 
se  expone  el  hecho  de  que  muchos  otros  casos  ofrecen  una  resistencia  con- 
ciderable,  mas  no  de  un  grado  suficiente  para  detener  el  curso  de  la  afeccion. 

1.  Que  la  hiperplacia  tuberculosa  de  la  laringe  pude  terminar  en  resolu- 
ci6n, 

2.  Que  ulceras  tuberculosas  de  la  laringe  pueden  curarse  algunas  veces. 

3.  Que  cualidades  negativas  favorables,  las  cuales  indican  una  resisten- 
cia superior,  es  caracterlstico  de  los  casos  capaces  de  recuperar. 

4.  Que  despues  de  un  periodo  razonable  de  observaci6n,  durante  el 
cual  estas  cualidades  persisten,  debera  distinguirse  los  casos  capaces  de 
recuperar. 


24  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

Nuestra  concepcion  comiin  de  la  tuberculosis  de  la  laringe,  se  determina 
por  medio  del  curso  de  6sta  en  unas  dos  quintas  partes  de  los  casos;  los 
casos  irresistibles.  Casi  dos  quintas  partes  de  los  casos  constituye  un 
grupo  en  el  cual  las  complicaciones  de  la  laringe  toman  un  curso  mas  lento, 
pero  siempre  fatal.  En  una  quinta  parte,  las  lesiones  estan  en  estado  esta- 
cionario,  durante  5  a  6  anos.  Se  hace  referencia  a  los  metodos  del  trat- 
miento,  local  y  general. 


Tuberculose   des  Kehlkopfes:     die   der  Heilung   zugangliche  Form 
derselben   und   deren   Behandlungs-Prinzipien. — (Casselberry.) 

Man  ist  daran,  fiir  die  Tuberculose  des  Kehlkopfes  dasselbe  festzustellen, 
das  man  heute  mit  Bezug  auf  Lungentuberculose  als  Thatsache  betrachtet, 
dass  sich  namlich  in  gewissen  Individuen  eine  natiirliche  Resistenz  entwickle, 
die  weiteren  Fortschritten  des  Krankheitsprocesses  einen  Damm  stelle; 
und  dass  viele  andere  eine  wohl  ganz  bedeutende  Resistenz  entwickeln, 
die  jedoch  nicht  hinreicht  um  den  Stillstand  zu  bcwirken.     Es  ist  erwiesen: 

1.  Dass  tuberculose  Hyperplasie  des  Kehlkopfes  der  Absorption  zu- 
ganglich  ist. 

2.  Dass  unanfechtbar  tuberculose  Geschwiire  gelegentlich  ausheilen. 

3.  Dass  jene  Falle,  die  sich  als  heilfahig  erwiesen  haben,  gewohnlich 
durch  giinstige  negative  Symptome  gekennzeichnet  sind,  welche  auf  hohere 
Widerstandskraft  und  giinstigere  Aussicht  auf  Heilung  schliessen  lassen. 

4.  Erwiesen  sich  diese  Eigenschaften  fiir  eine  angemessene  Beobach- 
tungsperiode  als  stabil,  so  sollte  es  keine  Schwierigkeiten  bereiten,  die 
der  Heilung  zuganglichen  Falle  differenzieren  zu  konnen. 

Die  allgemeine  Anschauung  iiber  die  Tuberculose  des  Kehlkopfes  stiitzt 
sich  auf  den  vexierenden  Verlauf  von  der  zwei  Fiinftel  der  Falle  bilden- 
den  wiederstandslosen  Form.  Fast  zwei  Fiinftel  der  Falle  reprasenteiren 
eine  Gruppe,  in  welcher  die  Complication  im  Kehlkopfe  einen  viel  langsa- 
meren,  wenn  auch  schliesslich  fatalen  Verlauf  nahm.  In  einem  Fiinftel 
war  seit  fiinf  bis  acht  Jahren  Stillstand  eingetreten. 

Die  anerkannten  localen  und  allgemeinen  Behandlungsmethoden  finden 
entsprechende  Wiirdigung. 


Tuberculose  du  Larynx:  le  Type  Susceptible  de  Gudrison. — (Casselberry.) 

On  cherche  a  etablir  pour  la  tuberculose  laryngienne  le  fait  deja  de- 
montre  pour  la  tuberculose  pulmonaire;  que  certaines  personnes  develop- 
pent  en  elles  une  resistance  naturelle,  suffisante  pour  enrayer  la  maladie. 


LARYNGEAL    TUBERCULOSIS! — THE   CURABLE   TYPE. — CASSELBERRY.      25 

et  qu'un  bien  plus  grand  nombre  offrent  une  resistance  considerable,  a 
laquelle  il  ne  manque  peut-etre  que  le  degre  requis  pour  enrayer  le  mal. 
On  fait  voir: 

1.  Que  rhyperplasie  tuberculeuse  dans  le  larynx  est  resoluble. 

2.  Que  des  ulceres  surement  tuberculeux  se  cicatrisent  parfois- 

3.  Que  les  qualites  negatives  favorables  qui  accusent  une  resistance 
superieure  et  annoncent  une  issue  plus  heureuse  caracterisent  commune- 
ment  les  cas  que  Ton  sait  etre  susceptibles  de  guerison. 

4.  Que,  ces  qualites  persistant  apres  un  temps  raisonnable  d'observa- 
tion,  on  devrait  pouvoir  differencier  les  cas  curables. 

Notre  idee  banale  de  la  tuberculose  du  larynx  est  tiree  de  sa  marche 
navrante  dans  a  peu  pres  deux  cinquiemes  des  cas,  le  type  d^pourvu  de 
resistance.  Presque  deux  cinquiemes  composent  un  groupe  ou  la  com- 
plication laryngienne  suit  un  cours  beaucoup  plus  lent,  cependant  fatal. 
Dans  I'autre  cinquieme  les  lesions  sont  dans  un  etat  d'arret,  de  5  a  8  ans. 
Apergu  des  m^thodes  approuv4es  de  traitement  local  et  general. 


THE  OPHTHALMO-TUBERCULIN  TEST: 

A  NOTE  ON  ITS  VALUE  IN  THE  QUESTION  OF  SURGICAL  TREAT- 
MENT OF  ORBITAL  DISEASE. 

By  Charles  A.  Oliver,  A.M.,  M.D., 

Philadelphia. 


Within  the  past  six  months  three  cases  of  localized  orbital  disease,  of 
uncertain  etiology,  have  been  submitted  to  my  judgment  as  to  the  advisa- 
bility of  operative  procedure.  Each  was  given  the  benefit  of  reaction-to- 
tuberculin  studies,  with  which  I  have  been  much  occupied  of  late.  The 
results,  in  every  instance,  were  those  of  undoubted  positive  reaction. 

Appropriate  tuberculin-therapy  was  applied  in  each  case,  with  the  result 
that  the  signs  and  the  symptoms  of  the  orbital  disturbance,  in  two  of  them, 
so  greatly  subsided,  in  four  and  a  half  months'  time  and  four  months'  time, 
respectively,  as  to  have  the  condition  for  which  the  patient  came  considered 
as  practically  well;  while  the  third,  which  is  under  active  treatment  at  the 
present  time  (June,  1908),  is  rapidly  undergoing  local  resolution.  The  health 
of  all  of  the  cases  has  remarkably  improved,  and  a  not  long  postponed 
general  recovery  is  expected. 

Without  entering  into  a  detailed  account  of  the  cases  in  such  a  brief 
communication  as  this,  and  reserving  a  full  report  of  them  for  a  more  ex- 
tended article  upon  the  subject,  I  herewith  give  the  following  reasons  which 
induced  me  to  resort  to  the  plan,  and  offer  a  few  conclusions  regarding  the 
usefulness  of  the  method  in  this  particular  type  of  disease. 

The  reasons,  briefly  stated,  were  that,  having  previously  noticed  that 
the  ophthalmo-reaction  in  many  of  my  ophthalmic  cases  was  more  pro- 
nounced in  young,  comparatively  sthenic  subjects,  with  the  less  marked 
and  the  more  uncertain  types  of  tubercular  lesions  of  the  corresponding  eye 
and  its  adnexa,  and  that  such  reaction  could  be  obtained  ^vith  even  the 
largest  percentages  of  reaction  material  without  any  damage  to  the  eyeball, 
I  came  to  the  conclusion  that  in  such  cases  the  test  must  prove  itself  of 
value,  not  only  in  regard  to  diagnosis,  but  in  reference  to  both  prognosis  and 
method  of  therapy. 

As  a  result,  I  offer  the  following  conclusions  in  support  of  the  method: 

I.  Ophthalmo-tuberculin  tests,  judiciously  used,  are  of  value  in  the 
determination  of  tuberculosis  of  the  corresponding  eye  and  its  adnexa, 

26 


THE   OPHTHALMO-TUBERCULIN   TEST. OLIVER.  27 

particularly  in  primary  infections  of  the  same,  and  should  be  made  in  every 
doubtful  case. 

II.  Ophthalmo-tuberculin  tests,  properly  employed  in  such  cases,  serve 
not  only  for  purposes  of  etiological  diagnosis,  but  are  of  importance  in  the 
determination  of  methods  of  treatment  for  the  removal  of  the  local  disease. 

III.  Ophthalmo-tuberculin  tests,  carefully  made,  should  form  a  part  of 
the  routine  study  employed  in  every  case  of  doubtful  disease  of  the  eyeball 
and  its  adnexa  before  any  proposed  operative  measures  are  resorted  to. 

IV.  Ophthalmo-tuberculin  tests,  conscientiously  applied  and  giving 
positive  determinative  results,  should,  whenever  possible,  be  followed  in 
part  or  in  whole  by  tuberculin-therapy. 


Valor  de  la  Prueba  Oftalmica  de  la  Tuberculina  en  el  Tratamiento  Quirtir- 
gico  de  las  Enfermedades  del  Ojo. — (Oliver.) 

Las  concluciones  son  las  siguientes: 

1.  La  prueba  oftalmica  de  la  tuberculina,  cuidadosemente  hacha,  es 
de  valor  en  la  determinacion  de  la  tuberculosis  en  el  ojo  correspondiente 
y  sus  anexos,  particularmente  en  las  infecciones  primarias,  y  debera  hacerse 
en  todos  los  casos  dudosos. 

2.  La  prueba  oftalmico  de  la  tuberculina,  propiamente  empleado,  sirve 
no  solamente  para  el  diagnostico  etiologico  de  la  enfermedad,  sino  qe  tam- 
bien  es  de  importancia  en  la  determinacion  de  los  metodos  del  tratamiento 
en  la  eliminacion  de  las  afecciones  locales. 

3.  Antes  de  recurir  al  tratamiento  operativo,  la  prueba  oftalmica  de  la 
tubercuhna  debera  constituir  una  parete  de  la  rutina  empleada  en  los  casos 
de  una  afeccion  dudosa  delojo  y  sus  anexos. 

4.  Los  casos  en  los  cuales  la  prueba  oftalmica  de  la  tuberculina  da  una 
reaccion  positiva,  deben  ser  seguidos,  en  parte  6  por  completo,  por  el  trata- 
miento de  la  tuberculina. 


La  valeur  de  la  reaction  ophtalmo-tuberculine  dans  le  traitement  chirur- 
gical  des  maladies  orbitaires. — (Oliver.) 

Voici  les  conclusions  proposees : 

1.  Les  reactions  ophtalmo-tuberculines,  judicieusement  employees,  sont 
importantes  pour  r^v^ler  la  tuberculose  de  I'ceil  correspondant  et  de  ses 
appendices,  surtout  dans  leurs  infections  primaires:  on  devrait  s'en  servir 
dans  tons  les  cas  douteux. 


28  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

2.  Ces  memes  reactions,  convenablement  employees  dans  ces  cas-1^, 
non-seulement  servent  aux  besoins  du  diagnostic  6tiologique,  mais  encore 
aident  a  choisir  les  methodes  de  traitement  pour  puerir  la  maladie  locale. 

3.  Employees  avec  soin,  ces  memes  reactions  devraient  faire  partie  des 
observations  routinieres  de  tous  les  cas  douteux  de  maladies  de  la  prunelle 
et  de  ses  appendices  avant  que  Ton  ne  recoure  aux  moyens  operatoires 
proposes. 

4.  Les  reactions  ophtalmo-tuberculines  consciencieusement  employees 
et  ayant  donn^  des  r^sultats  positivement  determinatifs,  il  faut,  toutes  les 
fois  qu'on  le  peut,  appliquer  en  tout  ou  en  partie  la  therapie  tuber culine. 


Ueber  den  Werth  der  Ophthalmo-Tuberculin-Probe  in  der  chirurgischen 
Behandlung  von  Erkrankungen  der  Augenhohle. — (Oliver.) 
Autor  kommt  zu  den  nachstehenden  Schlussfolgerungen : 

1.  Ophthalmo-Tuberculin-Proben,  wenn  mit  Discrimination  angewandt, 
bewahren  sich  in  der  Diagnose  von  Tuberculose  des  betreffenden  Auges  und 
dessen  Adnexa,  namentlich  in  Fallen  von  Primar-Infection,  und  sollten  in 
zweifelhaften  Fallen  stets  angewandt  werden. 

2.  Ophthalmo-Tuberculin-Proben,  wenn  in  solchen  Fallen  richtig  ange- 
wandt, dienen  nicht  bios  zur  Aufklarung  der  Aetiologie  der  Erkrankung, 
sondern  sind  auch  von  Wichtigkeit  in  Bestimmung  des  gegen  die  Ausrottung 
der  Localerkrankung  gerichteten  Heilverfahrens. 

3.  Bei  Erkrankungen  des  Augapfels  und  dessen  Adnexe  zweifelhaften 
Characters  sollten  Ophthalmo-Tuberculin-Proben  stets  schalblonenmassig 
angewandt  werden,  bevor  zu  chirurgischen  Massnahmen  geschritten  wird. 

4.  Falle,  in  welchen  Ophthalmo-TubercuHn-Proben,  richtig  angewandt, 
von  positivem  Ergebnisse  begleitet  sind,  sollten,  wenn  moglich,  stets  theil- 
weise  oder  durchgehend  mit  Tuberculin  behandelt  werden. 


TUBERCULOSIS   OF   THE   CORNEA. 

By  Oscar  Dodd,  M.D., 

Chicago. 


It  is  only  within  a  short  time  that  tubercular  conditions  of  the  eye  have 
been  recognized,  especially  those  forms  which  occur  with  a  latent  general 
tuberculosis.  Undoubtedly,  the  number  would  be  much  larger  if  we  ex- 
amined more  carefully  many  of  the  obscure  cases  of  chronic  inflammation 
of  the  iris,  ciHary  body,  and  choroid.  The  diagnosis  has  been  practically 
impossible  unless  some  part  could  be  removed  for  culture  or  injection.  For- 
tunately, at  present  we  have  in  tuberculin  injections  a  safe  and  compara- 
tively sure  method  of  diagnosis. 

My  reason  for  considering  tuberculosis  of  the  cornea  is  that  it  presents 
a  unique  clinical  picture  in  having  the  lesions  in  a  transparent,  non-vascular 
structure,  allowing  of  careful  observation  of  its  progress  and  the  effect  of 
treatment.  In  studying  the  cases  I  find  that  the  changes  apparent  in  the 
cornea  are  as  sensitive  to  treatment  as  the  opsonic  index. 

A  few  primary  cases  have  been  observed  from  direct  infection  after 
slight  injuries  of  the  corneal  epithehum,  but  most  frequently  it  occurs  by 
extension  from  the  surrounding  parts  or  by  endogenous  infection  from  foci 
in  other  parts  of  the  body. 

Stock,  by  his  experiments  on  rabbits,  has  shown  how  this  may  occur. 
By  injecting  tubercle  bacilli  into  the  veins  of  the  ear  he  obtained  foci  in  the 
choroid,  ciliary  body,  and  iris.  Instead  of  increasing  rapidly  in  size  and 
finally  destrojdng  the  eye,  as  happens  when  bacilli  are  introduced  directly 
into  the  anterior  chamber,  it  was  found  that  these  lesions,  as  a  rule,  under- 
went spontaneous  healing.  In  the  internal  organs  of  all  the  animals,  how- 
ever, typical  caseating  tubercles  occurred.  He  attributed  the  mild  charac- 
ter of  the  lesions  largely  to  the  fact  that  the  bacilli  were  confined  to  the  blood- 
vessels, and  thus  exerted  less  toxic  action  on  the  tissues,  and  to  the  special 
nutrition  and  resistance  of  the  eyeball.  This  seems  very  doubtful  consid- 
ering the  susceptibility  of  the  eye  to  other  poisons. 

The  foci  in  the  anterior  part  of  the  eye  are  more  likely  to  persist  than 
those  farther  back.  A  large  focus  could  exist  in  the  ciliary  body  without 
giving  any  symptoms  of  cyclitis.  He  was  never  able  to  demonstrate  the 
tubercle  bacilli  in  the  lesions,  although  he  did  not  doubt  their  presence. 

29 


30  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

In  a  more  recent  article  he  describes  an  experiment  which  seems,  without 
doubt,  to  demonstrate  their  presence.  From  the  iris  of  an  animal  in  which 
the  lesions  were  apparently  completely  healed  he  removed  a  piece  of  the 
tissue  and  introduced  it  into  the  anterior  chamber  of  a  healthy  rabbit.  In 
the  latter  it  gave  rise  to  the  typical  caseating  form  of  tuberculosis.  This 
also  illustrates  the  fact  that  tubercle  bacilli  or  spores  may  remain  dormant 
in  lesions  which  are  apparently  healed  for  long  intervals,  and  may  then 
become  active  upon  stimulation. 

Two  general  types  of  the  disease  are  seen:  (a)  That  of  a  general  paren- 
chymatous keratitis,  and  (6)  that  of  a  sclerosing  keratitis  in  which  the  process 
extends  from  the  corneal  margin  into  the  deep  corneal  tissue. 

(a)  The  general  haziness  of  the  first  type  is  explained  as  due  to  the  toxins 
produced  by  a  tubercular  inflammation  of  the  uveal  tract.  Usually,  when 
the  haziness  clears  up,  a  number  of  spots  are  seen  throughout  the  deeper 
layers  of  the  cornea.  The  vascularity  is  usually  much  less  than  occurs 
with  the  luetic  form. 

Enslin,  upon  testing  24  cases  of  interstitial  keratitis,  found  8  which 
reacted  to  tuberculin.  Of  these,  5  had  tuberculosis  or  a  predisposition  to  it, 
and  3  had  symptoms  both  of  tuberculosis  and  of  lues. 

(6)  The  sclerosing  form  I  believe  to  be  more  common  and  typical  of 
tuberculosis.  The  corneal  infiltration  is  usually  preceded  by  swellings  near 
the  corneal  margin,  which  resemble  phlyctenular  inflammation  very  closely. 
These  vary  in  extent  from  one  or  two  spots  to  practically  surrounding  the 
whole  cornea.  Verhoeff  believes  they  are  typical  of  tuberculosis,  as  he 
found  them  present  in  all  his  cases  of  scleritis  which  gave  a  local  as  well  as 
a  general  reaction  to  tuberculin.  Microscopically,  he  found  that  they  were 
typical  tubercle  foci  consisting  of  epithelioid  with  occasional  giant-cells 
surrounded  by  lymphoid  and  plasma  cells.  He  noted  their  variation  in 
appearance,  as  they  seemed  to  come  and  go  at  intervals  of  a  few  days.  This 
is  probably  due  to  the  surrounding  edema,  which  varies  with  the  activity 
of  the  tubercle  bacilli.  They  are  of  the  same  nature  as  the  spots  in  the 
cornea  as  found  by  others. 

The  corneal  infiltration  begins  at  these  places  and  extends  toward  the 
center,  usually  in  a  triangular  form.  There  are  a  number  of  discrete,  yel- 
lowish-white spots,  resembling  broken-down  tissue,  surrounded  by  more  or 
less  general  haziness.  A  few  blood-vessels  are  seen  in  the  deeper  layers 
extending  into  these  foci,  but  the  vascularity  is  never  very  marked.  The 
surface  of  the  cornea  may  have  the  roughened,  stippled  appearance  of  an 
ordinary  interstitial  keratitis,  but  is  frequently  unchanged. 

The  eye  has  more  or  less  general  inflammation,  with  the  symptoms  of  a 
cyclitis.  The  deposits  on  the  posterior  surface  of  the  cornea,  when  present, 
are  large  and  resemble  fat-drops.  In  some  instances  invasion  of  the  cornea 
has  been  noted  from  these  deposits. 


TUBERCULOSIS  OF  THE  CORNEA. — DODD.  31 

Occasionally  the  uveitis  is  of  a  plastic  form.  In  one  of  my  cases  there 
was  complete  adhesion  of  the  iris  to  the  lens,  and  the  pupil  was  filled  with 
exudate. 

The  course  of  the  disease  is  a  decidedly  chronic  one,  for  while  in  the  more 
vascular  parts  of  the  eye  there  is  a  tendency  to  healing  by  the  encapsulation 
of  the  foci,  in  the  cornea  they  will  exist  for  months.  New  foci  "^ill  appear 
and  old  ones  slowly  be  absorbed.  Ordinary  treatment  apparently  has 
little  effect  upon  the  process,  although  it  may  quiet  the  inflammation  and 
irritation. 

In  a  case  shown  by  Dr.  Wilder  before  the  Chicago  Ophthalmological 
Society  the  deposits  in  one  cornea  cleared  up  under  general  treatment.  Six 
months  later  it  began  in  the  other  eye,  and  grew  much  worse  under  treatment 
until  tuberculin  was  used,  when  recovery  took  place. 

In  my  cases  I  used  the  old  tuberculin  in  a  medium-sized  dose  for  diag- 
nostic purposes.  It  was  followed  by  a  local  as  well  as  general  reaction. 
The  new  Koch  tuberculin  (T.  R.)  was  used  in  increasing  doses  for  treatment 
under  opsonic  control,  never  giving  it  when  the  opsonic  index  was  low. 
Veiy  slight  local  reaction  was  obtained  except  when  too  large  a  dose  was 
given.  In  one  of  my  cases  the  dose  was  increased  too  rapidly,  and  it  was 
followed  by  marked  infiltration  into  the  cornea,  with  some  new  foci  showing. 
The  eye  was  considerably  inflamed,  and  it  took  several  days  before  it  cleared 
sufficiently  to  allow  further  treatment. 

The  improvement  was  veiy  noticeable  from  the  tuberculin  treatment, 
the  general  inflammation  subsiding  and  the  spots  in  the  cornea  disappearing, 
leaving  scarcely  a  trace  of  their  former  location. 

As  to  its  method  of  action,  judging  from  the  observation  of  those  cases, 
it  seemed  to  be  by  the  increased  vascularity  and  greater  supply  of  Ij^mph- 
cells  about  the  foci.  With  this  occurred  the  increased  ability  to  destroy 
the  bacilli,  as  shown  by  the  higher  opsonic  index.  This  action  can  be  in- 
creased, as  has  been  frequently  pointed  out,  by  good  food,  fresh  air,  etc., 
which  should  also  be  considered  in  the  treatment. 

I  will  briefly  report  two  private  cases  which  I  have  had  under  treatment: 

A  girl,  aged  fourteen,  came  to  me  in  October,  1906,  giving  a  history  of 
having  had  inflammation  of  the  right  eye  for  about  three  weeks.  She  was 
well  developed  and  apparently  in  good  health,  but  rather  anemic.  Her 
family  history  was  good.  There  was  a  marked  swelling  at  the  corneal 
margin  of  the  right  eye,  and  some  infiltration  in  the  cornea.  The  eye  was 
painful  and  very  sensitive  to  light.  The  left  eye  was  somewhat  inflamed, 
with  two  small  spots  of  infiltration  at  the  corneal  margin.  I  considered 
the  case  one  of  phlyctenular  inflammation,  and  sent  her  to  the  hospital  to 
be  treated  as  such.  It  grew  much  worse,  and  some  iritic  adhesions  formed. 
By  the  last  of  November  the  swelling  and  irritation  had  subsided  somewhat. 
In  the  deep  corneal  tissue  were  a  number  of  small,  sharply  defined  spots  of 


32  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

infiltration,  looking  like  broken-down  tissue,  and  some  vascularity  passing 
from  the  margin  into  these  spots.  She  was  taken  with  diphtheria,  and  I 
did  not  see  her  until  the  last  of  December.  The  condition  was  then  about 
the  same,  the  eye  fairly  quiet  under  atropin,  but  would  congest  easily. 
During  her  first  stay  in  the  hospital  she  had  no  rise  in  temperature  at  any 
time  during  the  day.  I  had  her  return  to  the  hospital  again  on  January 
10th  and  her  temperature  taken  frequently  for  several  days,  but  found  it 
perfectly  normal.  Her  opsonic  index  was  taken  on  three  succeeding  days, 
and  found  below  normal.  We  then  gave  her  a  diagnostic  dose  of  5  mg.  of 
old  tuberculin,  and  twenty-six  hours  later  got  the  maximum  reaction.  Her 
temperature  was  102i°,  pulse  120,  and  she  complained  of  severe  headache, 
some  nausea,  and  pains  in  her  body.  This  began  to  subside  in  two  hours, 
and  on  the  following  day  her  temperature  was  normal.  The  local  reaction 
was  very  marked,  the  eye  became  much  inflamed,  and  about  the  foci,  which 
were  previously  sharply  defined  and  distinct,  there  was  a  large  amount  of 
general  infiltration  and  an  increased  vascularity.  At  the  temporal  side  a 
new  focus  became  visible,  in  which  the  sharply  defined  spots  showed  later. 
The  general  haziness  resulting  from  this  injection  did  not  clear  up  for  several 
days.  About  ten  days  later,  her  opsonic  index  having  risen  to  normal,  an 
injection  of  Koch's  new  tuberculin  (T.  R.)  was  given,  which  gave  some  local 
reaction.  Six  days  later  she  was  given  a  larger  dose  of  tuberculin,  and  two 
days  later  her  opsonic  index  was  considerably  reduced,  and  she  complained 
of  some  pain  in  her  knees,  which  may  have  been  the  result  of  the  injection. 
This  was  followed  by  marked  irritation  of  the  eye,  which  did  not  subside 
for  several  days.  I  was  careful  after  this  not  to  have  too  large  a  dose  of  the 
tuberculin  given,  and  did  not  have  the  troublesome  reaction  again.  She 
was  given  about  twelve  injections  altogether,  the  last  one  about  three 
months  after  beginning  the  treatment. 

The  corneal  infiltration  disappeared,  so  it  was  hardly  apparent,  a  little 
haziness  remaining  only  at  the  site  of  the  denser  infiltrations.  Her  vision 
became  about  normal. 

One  of  the  most  marked  things  during  her  treatment  was  the  improve- 
ment in  the  general  condition;  her  color  was  greatly  improved,  and  her 
weight  increased  several  pounds. 

This  case  illustrates  well  the  effect  of  tuberculin  treatment  in  these  cases. 
While  the  use  was  controlled  by  the  opsonic  examination,  yet  the  corneal 
condition  was  a  good  indication  of  the  care  necessary  in  its  use.  Whenever 
a  large  dose  was  given,  the  infiltration  into  the  cornea  was  noticeably  in- 
creased, and  the  congestion  of  the  eye  more  marked. 

In  another  case  the  general  condition  did  not  improve,  as  in  the  first, 
as  there  was  a  great  amount  of  glandular  infection;  but  the  tuberculin 
treatment  brought  about  a  practical  cure  of  the  ocular  inflammation. 

A  boy,  nine  years  old,  came  to  me  in  December,  1907,  giving  the  history 
of  trouble  with  his  eyes,  and  having  been  treated  for  interstitial  keratitis 
for  several  months  with  no  benefit.  He  was  a  small  anemic  child,  no  larger 
than  he  should  have  been  at  six.  His  sight  was  very  poor,  the  left  eye  being 
practically  blind.     Both  eyes  were  greatly  inflamed,  with  great  photophobia. 


TUBERCULOSIS    OF   THE    CORNEA. — DODD.  33 

The  right  cornea  was  hazy  and  vascular,  the  iris  adherent  to  the  lens,  but 
some  red  reflex  could  be  gotten.  The  cornea  of  the  left  eye  was  quite  opaque, 
with  considerable  vascularity,  and  in  the  central  part  were  some  white  spots, 
looking  like  calcareous  degeneration.  The  pupil  was  entirely  filled  with  ex- 
udate, and  the  iris  completely  adherent.  I  sent  Mm  to  the  hospital  for  treat- 
ment. He  had  an  increase  of  temperature  every  afternoon,  which  usually 
did  not  exeeed  99.2°.  His  opsonic  index  was  generally  low,  but  varied 
greatly.  He  was  given  general  tonics  and  small  injections  of  new  tuberculin 
(T.  R.)  with  atropin  and  dionin  in  the  eyes.  His  eyes  and  general  condition 
improved  steadily,  but  the  afternoon  rise  in  temperature  still  continued. 
The  cornese  cleared  almost  completely,  and  the  inflammation  and  irritation 
of  the  eyes  subsided  so  that  he  was  able  to  see  very  well  with  the  right  eye. 
He  had  some  tubercular  cervical  glands  which  he  was  advised  to  have  re- 
moved, but  the  family  would  not  consent,  and  he  was  taken  home  about 
April  1st.    The  improvement  in  his  ocular  condition  still  remains. 


Tuberculosis  de  la  Cornea. — (Dodd.) 

Esta  rara  condicion  presenta  un  cuadro  clinico  unico,  en  que  las  lesiones 
son  de  estructura  transparente  y  permiten  la  obsei-vacion  cuidadosa  de  su 
progreso  y  de  los  efectos  del  tratamiento.     Es  casi  siempre  secundaria. 

El  signo  preventivo  de  costumbre  es  la  inflamacion  de  la  margen  de  la 
cornea  que  semeja  una  conjuntivitis  flictenular.  Esta  compuesta  de  dimin- 
utos  focos  de  celulas  gigantes  y  epiteloideas  en  las  cuales  se  encuentra 
algunas  veces  el  bacilo  de  la  tuberculosis.  Estos  focos  se  extienden  gradual- 
mente  hacia  la  cornea  y  rodeados  de  los  elementos  celulares  infiltrantes 
forman  el  cuadro  clinico  tlpico  de  esta  condicion.  El  tratamiento  ordinario 
tiene  muy  poco  efecto  en  estas  afecciones  que  duran  raeses.  La  mas  ligera 
irritacion  produce  nuevos  focos. 

Las  injecciones  de  tuberculina  con  el  objeto  de  hacer  un  diagnostic© 
producen  una  reaccion  local  y  general  que  se  manifesta  por  inflamacion 
marcada  del  ojo,  aumento  de  la  infiltration  cornea  y  produccion  de  nuevos 
focos.  Con  el  uso  de  la  tuberculina  (T.  R.)  en  dosis  pequenas,  los  focos 
desaparecen  y  raramente  dejan  opacidad  alguna. 

Las  dosis  mayores  de  tuberculina  producen  un  aumento  de  la  infiltra- 
cion  que  tarda  varios  dias  en  desaparecer.  Esto  demuestra  la  necesidad 
de  ser  mas  cuidadoso  en  su  uso  para  evitar  perjuicios  y  favorecer  el  au- 
mento de  resistencia  al  progreso  de  la  enfermedad. 


Tuberculose  de  la  com^e. — (Dodd.) 
Cette  affection  rare  presente  un  tableau   clinique  unique,  les  lesions 
ayant  une  structure  transparente,   qui  permet  d'observer  attentivement 
leur  progres  et  I'effet  du  traitement.     Cette  maladie  est  presque  toujours 

VOL.  II— 2 


34  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

secondaire.  Elle  commence  d'habitude  par  une  enflure  du  bord  de  la 
cornea,  enflure  qui  ressemble  a  une  conjonctivite  phylctenulaire,  et  qui,  se 
compose  de  petits  foyers  de  cellules  epithelioides  et  de  cellules  geantes 
contenant  quelquefois  Ics  bacilles  de  la  tuberculose.  Ces  foyers  s'^tendent 
petit  a  petit  a  la  cornee  et,  avec  1 'infiltration  generale  de  cellules  rondes 
autour  d'eux,  produisent  le  tableau  clinique  dont  nous  avons  parle  plus 
haut.  Le  traitement  ordinaire  a  tres  peu  d'effet  sur  cette  maladie,  qui 
dure  pendant  des  mois,  de  nouveaux  foyers  prenant  naissance  a  chaque 
legere  irritation.  Les  injections  de  tuberculine  pour  le  diagnostic  ont 
pour  effet  une  reaction  generale  et  locale,  qui  se  manifeste  par  une  inflamma- 
tion remarquable  de  I'oeil,  par  une  plus  grande  infiltration  de  la  cornee 
et  par  la  formation  de  foyers  nouveaux.  Par  Temploi  de  la  tuberculine 
nouvelle  (T.  R.)  en  petites  doses,  les  taches  disparaissent,  laissant  rarement 
une  opacite  apres  elles.  Ces  experiences  montrent  combien  de  soin  on  doit 
prendre  dans  I'eraploi  de  la  tuberculine  pour  ne  pas  faire  de  mal  et  pour  pro- 
voquer  une  plus  grande  resistance  contre  le  progres  de  la  maladie. 


Tuberkulose  der  Cornea. — (Dodd.) 

Diese  seltene  Erscheinung  prasentiert  ein  einzig  darstehendes  klinisches 
Bild,  indem  die  Verletzungen  von  einer  durchsichtigen  Struktur  sind, 
eine  sorgfaltige  Beobachtung  ihres  Fortschreitens  und  der  Wirkung  der 
Behandlung  erlauben.     Es  ist  fast  immer  secundar. 

Der  gewohnliche  Vorlaufer  ist  ein  Geschwulst  am  Rande  der  Cornea, 
welche  ahnlichkeit  mit  phlyctenularer  Conjunctivitis  hat.  Dieser  ist  von 
kleinen  Herden  epithelioider  und  Riesenzellen  zusammengesetzt  in  welchen 
die  Tuberkelbacillen  gelegentlich  gefunden  werden.  Diese  Herde  erst- 
recken  sich  nach  und  nach  in  die  Cornea,  und  mit  der  allgemeinen  Rund- 
zelleninfiltration  um  sie  herum  geben  sie  Veranlassung  zu  dem  typischen 
klinisclien  Bilde.  Gewohnliche  Behandlung  hat  auf  diese  Erscheinungen 
sehr  wenig  Wirkung,  da  sie  Monate  lang  andauern,  und  auf  die  leicliteste 
Irritation  ein  neue  Herde  entstehen.  Tuberkulininjektionen  zu  diag- 
nostischem  Zwecke  verursachen  eine  allgemeine  und  auch  eine  lokale  Reak- 
tion,  welche  sich  durch  bemerkbare  Entziindung  des  Auges  stiirkere  Infil- 
tratbildung  in  die  Cornea  und  die  Bildung  neue  Herde  manifestiert.  Durch 
den  Gebrauch  des  neuen  Tuberkulins  (T.  R.)  in  kleinen  Dosen  verschwinden 
die  riecke  und  lassen  selten  eine  Triibung  zuriick.  Einer  zu  grossen  Tuber- 
kulindosis  folgt  fast  immer  ein  Vermehrung  der  Infiltration,  die  erst  nach 
einigen  Tagen  zuriickgeht.  Das  zeigt,  dass  Sorgfalt  notig  ist  um  in  seiner 
Anwendung  Schaden  zu  verhindern  und  nur  ein  verstarkte  Widerstands- 
fahigkeit  gegen  den  Fortschritt  der  Krankheit  zu  schaffen. 


TUBERCULAR   DISEASE   OF   THE  MIDDLE   EAR. 
By  Clarence  John  Blake,  M.D., 

Boston. 
(Presented  by  Dr.  H.  O.  Reck,  Baltimore.) 


The  clinical  characteristics  of  a  tubercular  invasion  of  the  middle  ear 
may  be  said  to  be  the  apparent  suddenness  of  its  onset,  the  comparative 
painlessness  of  its  course,  and  the  rapidity  with  which  an  extensive  destruc- 
tion of  tissue  is  accomplished. 

This  picture  is  so  definite  in  its  outline,  the  composite  resulting  from  the 
superposition  of  a  number  of  recorded  cases  by  different  observers  is  so  clear, 
that  it  does  not  need  to  be  enlarged  for  the  purpose  of  investigation  as  to 
the  causes  underlying  this  uniformity  of  manifestation,  and  the  determina- 
tion of  the  presence  of  the  tubercle  bacillus  may  be  regarded  as  superfluous 
to  the  diagnosis,  when  the  aural  characteristics  are  taken  in  conjunction 
with  the  evidences  of  tubercular  disease,  to  which  the  aural  implication 
occurs  as  a  supplemental  process. 

As  to  the  mechanism  of  infection  of  a  cavity,  which  would  seem  to  be 
particularly  exjDOsed  because  of  its  relationship  to  other  frequently  primarily 
affected  parts,  and  particularly  susceptible,  because  of  the  contour  of  its 
interior  and  the  character  of  its  normal  contents,  the  majority  of  waiters 
are  of  the  opinion  that  this  comes  about  most  frequently  through  the  medium 
of  the  tympanopharyngeal  tube,  that  the  infection  is  a  primary  one,  so  far 
as  the  middle  ear  is  concerned,  and  that  it  does  not,  or  in  a  minority  of  cases 
only,  occur  participatively,  as  the  peripheral  exhibition  of  a  general  systemic 
affection. 

With  this  opinion  in  mind,  and  in  view  of  the  small  percentage  of  cases  of 
middle-ear  disease  of  tubercular  origin  in  the  very  considerable  number  of 
observed  cases  of  pulmonary  tuberculosis,  the  inference  is  at  least  permis- 
sible that  the  tubercular  implication  of  the  middle  ear  is,  in  the  main,  acci- 
dental, or  dependent  upon  structural,  and  uniformly  existent,  conditions. 

In  support  of  this  proposition  may  be  taken  the  direct  mechanical 
relationship  of  the  middle-ear  cavity  to  the  larger  cavity  of  the  nasopharynx 
and  the  intimate  reflex  and  circulatory  relationship  to  other  organs  which 
may  have  become  the  seat  of  tubercular  lesion. 

Tubercular  middle-ear  disease  develops  most  frequently  in  patients  with 

35 


36  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

pulmonary  tuberculosis,  and  seldom  with  tuberculosis  of  other  organs,  accord- 
ing to  Borbone,  and  is  most  frequently  caused  by  invasion  of  the  bacilli 
through  the  lumen  of  the  tube  itself,  or  along  the  subepithelial  tissue  of  its 
walls,  according  to  Politzer,  though  infection  through  the  blood  may  occur 
in  tuberculosis  of  the  glands  and  bones  or  in  miliary  tuberculosis,  according 
to  Barnick. 

The  primary  tuberculosis  manifesting  itself  mainly  in  the  mastoid  cavity 
has  its  origin  in  the  cancellous  spaces  of  the  bone,  through  the  medium  of 
the  circulation,  or  in  the  mucous  lining  of  the  pneumatic  cells  by  transmission 
through  the  tympanopharyngeal  tube.  These  cases  are  rare,  but  in  all  of 
them  there  is  the  excessive  infiltration  of  the  tissues  and  the  rapid  and  ex- 
tensive destruction  which  mark  the  progress  of  the  similar  infection  of  the 
tympanic  cavity. 

The  irregular  contour  of  the  epitympanum,  the  opportunities  thereby 
afforded  for  the  lodgment  of  infective  invaders,  and  the  complicating  presence 
of  numerous  folds  of  connective  tissue  and  exceedingly  vascular  reduplicate 
mucous  membrane,  present  a  favorable  field  for  the  exhibition  of  the  peculiar 
clinical  manifestations  of  the  tubercular  infection,  while  the  engorgement  of 
the  mucous  folds,  as  the  result  of  a  suspense  of  vasomotor  inhibition  incident 
to  reflex  relationship  with  the  pulmonary  and  nasopharyngeal  seat  of  bac- 
terial activity,  paves  the  way  for  that  infiltration  of  the  tissues,  in  the  im- 
plicated area,  which  lessens  their  resistance  to  invasion  and  favors  their 
more  rapid  destruction. 

This  condition,  which  may  occur  at  any  stage  of  pulmonary  tuberculosis, 
but  is  more  frequent  in  the  advanced  cases,  is  illustrated  by  the  painless 
onset  of  the  middle-ear  implication,  an  onset  also  characterized,  subjectively, 
by  impairment  of  hearing  to  sounds  aerially  conveyed,  sense  of  fullness  in 
the  depth  of  the  ear,  moderate  circulatory  tinnitus,  and,  objectively,  by 
edema  of  the  pars  flaccida  and  upper  portion  of  the  membrana  vibrans, 
especially  the  posterior  superior  segment,  with  little  or  no  injection  of  the 
manubrial  and  peripheral  blood-vessels,  a  picture  distinctly  differentiated 
from  the  objective  manifestation  of  epitympanic  implication  of  other  than 
tubercular  origin,  and  one  occurring,  moreover,  more  frequently,  in  the 
observed  cases,  in  the  ear  corresponding  to  the  side  upon  which  the  pulmon- 
ary manifestation  of  the  disease  was  more  pronounced.  So  rapid  is  the 
destructive  process  in  the  majority  of  these  cases  of  manifestation  of  tuber- 
cular infection  in  the  epitympanum  that  close  observation  is  necessary  to 
determine  their  course;  the  edema  is  liable  to  be  followed  by  a  rupture  of 
the  thin  and  distended  pars  flaccida,  and  succeeded  by  a  perforation  of  the 
posterior  superior  segment  of  the  membrana  vibrans,  extending  rapidly,  in 
some  instances,  to  almost  entire  destruction  of  the  membrane,  and  accom- 
panied by  the  outflow  of  a  thin  fluid,  clear  and  limpid,  or  slightly  discolored 


TUBERCULOSIS   OF   THE   MIDDLE    EAR. — BLAKE.  37 

and  curdy,  usually  odorless,  at  first,  but  later  becoming  fetid  as  the  destruc- 
tive process  invades  the  ossicular  articulations  and  bony  necrosis  begins. 

While  the  perforation  of  the  pars  flaccida  may  be  accounted  for  in  part 
mechanically,  in  the  extreme  distention  and  impaired  vitality  of  that  deli- 
cate membrane,  the  perforation  of  the  more  resistant  membrana  vibrans  is 
usually  effected  by  the  cheesy  infiltration  of  the  mucous  membrane  and  the 
formation  of  the  tubercle  nodules,  first  described  by  Schwartze,*  a  formation 
which  may  take  place  in  any  portion  of  the  membrana  vibrans,  or  at  several 
points  simultaneously,  thus  giving  rise  to  the  peculiar  multiple  perforations, 
coalescing  later  in  one  large  opening,  and  occurring  more  frequently,  in  the 
observation  of  Dr.  Buck  and  of  the  writerj  in  the  posterior  superior  segment. 

The  preliminary  objective  symptoms  of  a  perforation  of  this  kind  are  a 
circumscribed  area  of  vascular  injection,  upon  the  otherwise  pale  edematous 
drum-head,  with  one  or  more  distinctly  delineated,  pearl-like  spots  wliich 
mark  the  presence  of  the  tubercle  nodules.  At  these  spots  ulceration  occurs 
and  the  membrane  becomes  speedily  perforated. 

With  the  excessive  infiltration  of  the  lining  membranes  of  the  tympanic 
cavity,  membranes  so  intimately  associated  both  structurally  and  tlii'ough 
circulatory  anastomosis  as  to  partake  easily  in  subjection  to  so  destructive 
a  process  as  that  incident  to  tubercular  disease,  there  is  a  lowering  of  resis- 
tance which  favors  implication  of  the  underlying  bony  wall,  first,  through 
its  denudation,  and,  second,  through  the  translation  to  it  of  a  necrotic 
process. 

The  diseased  areas  of  bone  may  at  first  be  limited  and  confined  to  the 
ossicles,  especially  to  the  articulating  facets,  or  to  depressions  on  the  tym- 
panic walls,  but,  as  the  process  of  denudation  extends,  these  areas  extend 
also  and  become  correspondingly  penetrative.  Portions  which  are  readily 
denuded — the  rounded  surface  of  the  promontory,  for  instance — are  more 
subject  to  penetration,  and  cortical  labyrinthine  necrosis  is  a  not  infrequent 
implication  in  advanced  cases,  though  the  statistics  of  suppurative  invasion 
of  the  labyrinth  show  that  in  about  one-third  of  the  tubercular  cases  the 
passage  inward  has  been  through  the  labyrinthine  windows.  The  intra- 
capsular sequence  is  a  thickening  and  partial  destruction  of  the  membranous 
labyrinth,  with  cell-production  and  connective-tissue  formation.  According 
to  Politzer,t  tubercular  suppurations  of  the  middle  ear  lead  much  less 
frequently  to  intracranial  complications  than  do  the  ordinary  suppurations 
due  to  the  streptococcus.  Where  the  carious  process  of  the  petrous  bone  is 
extensive,  the  fatal  termination  is  caused  more  often  by  pulmonary  phthisis 
than  by  purulent  or  tubercular  meningitis,  brain  abscess,  or  sinus  phlebitis. 

*  "  Pathologische  Anatomie  des  Ohres,"  1878. 

t  Blake  and  Buck,  New  York  Medical  Journal,  1886. 

X  "Diseases  of  the  Ear,"  Ballin  and  Heller,  1903. 


38  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

There  is  another  pecuUar  aural  manifestation,  evidently  rare,  since  it 
does  not  find  its  place  in  the  literature  of  the  subject,  which  is  worthy  of 
the  attention  of  otologists,  and  that  is  the  edema  of  the  upper  portion  of  the 
drum-head,  without,  or  with  but  slight,  injection  of  the  blood-vessels  of  the 
corresponding  region,  observable  in  some  cases  of  tubercular  meningitis  in 
children  in  whom  the  anastomosis  between  the  intracranial  and  epitympanic 
circulation  would  provide  the  means  for  the  observed  condition.  In  these 
cases  there  is  usually  moderate  injection  of  the  larger  blood-vessels,  crossing 
the  posterior  segment  of  the  membrana  vibrans  from  above  downward,  and 
sometimes  in  small,  distinctly  circumscribed  area  of  congestion  on  the  pos- 
terior canal  wall. 

The  prognosis  in  tubercular  middle-ear  suppuration  is  usually  unfavor- 
able, especially  in  the  acute  cases,  where  there  is  early  evidence  of  the  im- 
plication of  the  labyrinth,  and  in  the  chronic  cases,  where  there  is  extensive 
soft-tissue  destruction,  bony  necrosis,  and  advanced  pulmonary  phthisis; 
but  with  the  localized  affection  in  the  mastoid,  for  instance,  in  children, 
early  operative  measures  may  be  favorably  effectual.  To  be  effectual, 
however,  they  should  include  thorough  and  painstaking  removal  of  all 
necrotic  and  congested  bone  down  to  the  surrounding  healthy  soft  tissue, 
muscle,  or  dura,  and  the  excision  of  all  neighboring  tubercular  glands. 

The  favorable  results  of  operation  include  mainly  the  cases  of  primary 
tuberculosis  of  the  mastoid  in  children  and,  in  adults,  the  cases  in  which 
the  pulmonary  affection  is  not  advanced.  In  the  majority  of  advanced 
cases,  with  extensive  necrosis  already  established,  operation  is  contrain- 
dicated  because  of  its  futility,  the  rule  in  the  operable  cases,  therefore,  being 
to  operate  as  early  as  is  possible  and  as  completely  as  is  necessary  and 
admissible.  In  the  non-operable  cases,  local  treatment  should  include  such 
thorough  cleansing  of  the  affected  parts  as  is  attainable,  and  such  limitation 
of  the  destructive  process  as  may  be  possible.  The  application  of  suction 
and  of  the  artificial  compression  hj^erkinesia  of  Bier  to  these  cases,  though 
ardently  advocated  by  some  observers,  has  as  yet  too  little  accumulated 
evidence  of  its  value  to  make  its  use  other  than  investigatory. 

The  demonstration  of  the  presence  of  the  tubercle  bacillus  in  the  dis- 
charge from  a  suppurative  middle  ear  is  one  of  such  difficulty  that  its  appar- 
ent absence  is  no  indication  that  the  process  is  not  tubercular.  The  suppur- 
ating middle  ear,  moreover,  exposed  by  the  destruction  of  its  soft  tissues 
and  with  its  resistance  capacity  reduced,  becomes  the  seat  of  other  invasions, 
and  a  mixed  infection  makes  exact  determination  very  difficult.  Under 
these  circumstances  the  value  of  exact  clinical  observation  of  objective 
symptoms  becomes  enhanced,  and  it  is  to  be  hoped  that  the  awakened 
conscience  of  the  past  decade,  which  has  stimulated  the  united  action  of  the 
medical  profession  and  the  public  in  the  present  campaign  against  a  dread 
disease,  will  find  an  answering  effort  on  the  part  of  investigation  in  otology. 


TUBERCULOSIS  OF  THE  MIDDLE  EAR. — BLAKE.  39 

La  Tuberculose  de  I'Oreille. — (Blake.) 
Les  aspects  cliniques  de  rinfection  tuberculeuse,,  tels  qu'on  les  voit  dans 
Toreille  moyenne,  et  les  consequences  montrees  dans  I'implication  avancee 
de  I'os  temporal  ont  ete  d^crits  par  les  premiers  otologistes;  mais  ce  n'est 
que  depuis  une  dizaine  d'annees  qu'on  s'est  occupe  soigneusement  d'une 
forme  d'infection  de  I'oreille  moyenne  et  du  labyi'inthe  caracterisee  par  une 
destruction  considerable  et  rapide  de  tous  les  tissus,  sans  parler  d'une  ab- 
sence particuliere  de  symptomes  subjectifs  preliminaires. 

La  susceptibilite  de  la  cavite  de  I'oreille  moyenne  k  I'infection,  par  I'in- 
termediare  du  tube  tympano-pharyngien,  et  le  caractere  et  la  location  des 
tissus  sensibles  dans  I'epitympanum  expliquent  I'implication  plus  commune 
de  cette  cavite,  tandis  que  la  singularite  des  symptomes  objectifs  d^montre 
I'importance  de  I'examen  aural  pour  un  diagnostic  differentiel. 


THE   SURGICAL  TREATMENT   OF   TUBERCULAR    LE- 
SIONS OF  THE  UPPER  RESPIRATORY  TRACT. 

By  D.  Braden  Kyle,  M.D., 

Philadelphia. 


The  surgical  treatment  of  tubercular  lesions  involving  the  structures  of 
the  upper  respiratory  tract  is  dependent  upon  a  number  of  conditions, 
namely,  whether  the  lesion  is  a  primary  or  a  secondary  one,  the  general 
condition  of  the  patient,  the  location  of  the  lesion,  and  the  structures  in- 
volved in  the  actual  lesion ;  also  whether  the  lesion  is  an  acute  one  or  in  its 
early  stages,  or  whether  it  is  a  chronic  process. 

There  has  been  considerable  discussion  and  difference  of  opinion,  as 
expressed  in  the  various  text-books  and  journalistic  literature,  as  to  the  exis- 
tence of  a  primary  lesion  involving  the  nose,  nasopharynx,  pharynx,  uvula, 
tonsil,  mucous  membrane  of  the  cheek  or  tongue,  and  of  the  pharynx. 
Personally,  there  is  no  doubt  in  my  mind  that  such  primary  lesions  do  exist, 
and  in  such  primary  lesions  surgical  interference  offers  more  in  a  curative 
way  than  when  such  lesion  is  secondary  to  structures  involved  elsewhere. 
Necessarily,  from  this  statement  would  be  deducted  the  fact  that  surgical 
interference  does  not  offer  much  in  tubercular  lesions,  as  the  majority  of 
tubercular  lesions  are  secondary.  This  certainly  has  been  my  experience 
in  private  and  hospital  practice,  that,  in  the  vast  majority  of  cases,  surgical 
interference  does  not  offer  much  in  a  curative  way,  but  occasionally  does 
afford  some  palliative  relief. 

That  tubercular  lesions  of  this  upper  respiratory  tract  usually  present 
themselves  in  one  of  three  conditions,  namely:  The  ulceration,  the  nodule 
involving  the  basement  membrane,  and  the  papillomatous  excrescences 
which  form  about  a  tubercular  area.  The  ulcerative  process  usually  shows 
a  mixed  infection,  which,  I  believe,  always  occurs  after,  and  not  before, 
the  ulceration. 

If  by  curettement  or  cauterization  or  by  the  use  of  the  knife  the  entire 
tubercular  area  could  be  removed,  then  such  interference  would  be  justified. 
Unfortunately,  however,  except  in  the  primary  lesion,  the  process  is  not 
limited  to  the  one  nodule,  and  post-mortem  examinations  in  such  cases  have 
always  shown  multiple  nodules  in  various  stages  of  development,  so  that  by 
the  mere  removal  of  one  nodule  only  temporary  relief  would  be  afforded. 

40 


TUBERCULOSIS   OF   THE    UPPER   RESPIRATORY   TRACT. — KYLE.  41 

Besides,  the  h-mphatic  areas  which  are  so  abundant  in  the  mucous  membrane 
structures  would  be  opened  up  for  further  infection,  as,  unfortunately,  the 
antiseptic  precautions  which  can  be  used  on  the  surface  of  the  body  cannot  be 
employed  in  operations  on  the  mucous  membrane.  i\Iany  cases  are  reported 
cured  b}'  the  use  of  cauteries,  caustics,  and  curettement.  Whether  they  were 
primary  cases  or  secondary  is  not  always  definitely  stated.  In  fact,  it  is 
a  question  that  is  often  very  difficult  to  determine,  but  in  some  of  the  cases 
unquestionably  the  chagnosis  of  tuberculosis  was  not  fully  established.  Un- 
less the  tubercle  bacillus  can  be  demonstrated  either  in  the  secretion  or  from 
direct  inoculation  from  the  infected  area,  I  certainly  would  insist  on  the 
therapeutic  test  being  employed  to  eliminate  the  possibility  of  the  lesion 
being  a  specific,  one.  Specific  lesions  about  the  upper  respiratory  tract 
more  frequently  yield  to  treatment  than  do  the  tubercular  ones.  In  a  prim- 
ary tubercular  lesion  involving  the  nasal  mucous  membrane,  especially  at 
the  junction  of  the  skin  and  mucous  membrane,  or  involving  the  uvula, 
the  tonsil,  or  the  tongue,  a  cure  may  be  perfected  by  thorough  excision. 
This,  however,  I  do  not  believe  to  be  true  when  it  involves  the  larynx.  As 
a  rule,  when  the  surgeon  is  consulted  in  regard  to  the  process  involving  these 
structures,  the  disease  is  well  advanced  and  has  been  treated  by  various 
agents,  irritant  and  otherwise,  and,  as  a  rule,  the  lesion  is  not  a  single  one, 
but  multiple.  The  efficiency  of  surgical  interference  under  such  conditions 
I  doubt  very  much. 

In  pulmonary  tuberculosis  with  local  lesions  in  the  larjmx,  especially 
involving  the  vestibule  and  the  vocal  cords,  there  is  sometimes  seen  a  granular 
condition  resembling  very  much  the  specific  granulomata.  In  several  cases 
I  have  seen  this  exist  to  such  an  extent  as  greatly  to  interfere  with  breatliing. 
Surgical  interference  in  the  way  of  removal  of  these  excrescences  "will  establish 
free  breathing,  and,  in  my  experience,  has  never  caused  any  spread  of  the 
disease  in  the  local  area.  These  excrescences,  however,  are  more  of  a  fibroid 
nature  and  have  very  little  epithelial  structure,  and  are  largely  devoid  of 
lymphatics,  which  may  account  for  the  fact  that  there  is  very  little  likelihood 
of  spreading  of  the  ulceration  following  any  destruction  of  tissue. 

Another  important  point  in  surgical  interference  is  this:  If  the  patient 
with  a  primary  or  secondary  lesion  is  in  a  climatic  condition  which  is  most 
favorable, — for  example,  the  high,  dry  altitudes  of  our  Rocky  Mountain 
States, — surgical  interference  certainly  offers  better  results  than  it  does  in  the 
low  altitudes,  as  in  the  middle  west  and  the  east. 

The  question  of  surgical  interference,  again,  is  also  largely  determined 
by  individual  patients;  with  extensive  glandular  involvement,  with  large 
localized  pulmonary  lesions,  with  the  general  condition  of  the  patient  away 
below  par,  no  matter  what  the  climatic  conditions,  surgical  interference  offers 
very  little  other  than  palliation.     Localized  tubercular  glands  of  the  neck, 


42  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

the  infection  of  which  probably  passed  through  the  tonsillar  tissue  or  the 
lymphatic  areas  of  the  nasopharynx,  and  became  localized  in  the  cervical 
glands,  do  not  present  the  same  surgical  aspect  as  a  local  lesion  of  the  mucous 
membrane.  A  tubercular  lesion  limited  to  the  tonsil,  by  thorough  removal 
of  the  infected  organ,  provided  infection  through  the  lymphatics  has  not 
already  taken  place,  may  remove  the  danger  of  any  sj^stemic  infection. 

To  my  mind  the  whole  matter  can  be  summed  up  in  this  way:  That  surgical 
interference  first  would  depend  on  the  indi\adual  case,  whether  it  is  primary 
or  secondary;  whether  the  lesion  is  single  or  multiple;  the  location  of  the 
lesion;  the  history  of  the  patient;  his  age  and  his  general  condition;  his 
surrouncUngs ;  the  climate;  his  ability  to  procure  nutritious  food  and  proper 
care — in  other  words,  that  surgical  interference  rarely  ever  offers  curative 
results,  but  is  frequently  palliative,  and  in  many  cases  would  be  decidedly 
detrimental,  and  only  tend  to  spread  the  disease.  In  advanced  cases  the 
tissue  resistance  is  very  poor,  and  by  opening  the  l^Tnphatics  you  only  insure 
further  invasion. 

In  purely  primary  local  lesions  involving  any  of  the  mucous  membrane 
of  the  upper  respiratory  tract,  if  seen  early,  surgical  interference  is  certainly 
justifiable  if  the  lesion  is  single,  and  a  thorough  removal  of  the  infected  area 
will  relieve  the  individual  of  any  danger  of  further  invasion ;  but  where  the 
lesion  is  secondary,  my  experience  has  been  that  surgical  interference  certainly 
offers  nothing  from  a  curative  standpoint.  A  tuberculous  nodule  is  not 
formed  until  the  connective  tissue  is  invaded.  When  such  a  nodule  is  de- 
tected, it  is  often  impossible  to  determine  whether  other  structures  have 
been  invaded  and  latent  lesions  formed,  which  may  develop  later,  giving  rise 
to  systemic  infection.  In  such  a  case,  surgical  interference  can  only  sub- 
ject the  patient  to  needless  suffering. 


TUBERCULOSIS  OF  THE  NOSE,  MOUTH,  AND 
PHARYNX.* 

By  Harris  Peyton  Mosher,  M.D., 

Boston. 


TUBERCULOSIS  OF  THE  NOSE. 

Owing  to  the  filtering  power  of  the  nose,  relatively  few  bacteria  reach  the 
pharynx.  In  addition  to  its  filtering  power,  the  nasal  cavity,  through  the 
secretions  of  the  mucous  membrane,  exerts  a  marked  inhibitory  growth 
upon  many  bacteria.  On  account  of  these  factors,  and,  in  addition,  owing 
to  the  slow  growth  of  the  bacillus  of  tuberculosis,  the  nasal  cavity  is  rarely 
the  primary  seat  of  tuberculosis. 

Tuberculosis  of  the  nose  occurs  in  two  forms: 

1.  The  first  form  of  tuberculosis  of  the  nose  is  a  local  affection,  occurring 
in  the  anterior  part  of  the  nasal  cavity,  in  the  region  of  the  triangular  cartilage 
of  the  septum.  Accompanying  this  form  there  are  few,  if  any,  manifes- 
tations of  tuberculosis  in  other  parts  of  the  body.  The  lesion  is  characterized 
by  a  flat  infiltration  or  a  superficial  ulceration.  It  is  very  suggestive  that 
the  tubercular  lesion  occurs  on  the  septum  at  the  point  where  ulcerations 
are  so  often  caused  by  picking  with  the  finger-nail. 

2.  The  second  form  of  tuberculosis  of  the  nose  is  characterized  by  a  suflEi- 
cient  overgrowth  of  tissue  to  result  in  tumor  formation.  It  is  usually  a 
complication  of  tuberculosis  of  the  lungs  or  of  the  pharynx. 

IMiCROscopic  Findings. — The  infiltration  consists  of  a  diffuse  collection 
of  round-cells  interspersed  with  a  few  giant-cells.  These  show  but  slight 
tendency  to  caseation.  Tubercle  bacilli  are  not  numerous,  so  that  they  are 
generally  very  hard  to  find. 

The  Gross  Appearance  of  the  Lesion. — The  infiltration  usually 
presents  a  superficial  ulceration,  which  has  an  irregular  edge.  This  is  often 
undermined.  The  ulceration  is  covered  with  a  mucopurulent,  odorless 
secretion.  There  may  be  a  slight  odor,  but  it  is  never  very  pronounced. 
The  ulcer  has  a  rim  of  granulations  or  tubercles,  and  similar  tubercles  are 
dotted  over  its  floor.  The  tubercular  process  attacks  first  the  mucous 
membrane,  then  the  cartilage,  and  finally  the  opposite  mucous  membrane. 

*  In  this  paper  the  writer  has  made  free  use  of  the  articles  of  Wood,  Levy,  and 
Zarniko. 

43 


44  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

The  result  of  this  is  a  bilateral  swelling  of  the  anterior  cartilaginous  part 
of  the  septum,  which  may  block  the  lumen  of  the  nose.  In  time  the  floor 
of  the  nose,  the  inferior  meatus,  and  the  inferior  turbinates  become  involved. 
In  such  extensive  cases  the  infection  may  work  its  way  to  the  pharynx  or 
even  to  the  lar)Tix.  Sometimes,  in  these  veiy  cases,  the  bony  structures 
become  involved. 

The  Course  and  Symptoms  of  Tuberculosis  of  the  Nose. — The 
course  of  tuberculosis  of  the  nose  is  very  chronic.  There  is  no  pain,  unless 
secondary  infection  takes  place.  The  patient  complains  only  of  nasal 
obstruction  and  an  increase  of  secretion. 

Complications. — The  tubercular  process  may  extend  to  the  pharynx,  or  it 
may  travel  up  the  tear-duct  to  the  conjunctiva.  Often  the  retropharyngeal, 
the  submaxillary,  or  the  jugular  glands  become  infected. 

Tuberculosis  of  the  Nasal  Mucous  Membrane  and  Lupus. 

In  many  cases  where  there  is  tuberculosis  of  the  nasal  mucous  membrane 
there  exists,  at  the  same  time,  lupus  of  the  tip  or  of  the  alae  of  the  nose.  The 
process  in  the  two  places  is  so  similar  that  many  writers,  with  good  reason, 
consider  them  the  same  condition.  Caboche  maintains  that  the  process  in 
the  nose  is  the  same  as  the  process  in  the  skin,  and  that  both  are  lupus.  He 
holds,  further,  that  lupus  of  the  face  is  always  primary  in  the  nose.  If  this 
is  true,  it  is  a  very  important  fact  in  the  treatment  of  lupus  of  the  face.  This 
writer  holds  that,  wherever  there  is  a  perforation  of  the  cartilage  of  the 
septum  combined  with  destruction  of  the  alse  of  the  nose,  the  disease  is  not 
tuberculosis,  but  lupus.  Long-continued  eczema  of  the  nares  raises  the 
suspicion  of  beginning  lupus. 

Diagnosis. — In  making  a  diagnosis  of  tuberculosis  of  the  mucous  mem- 
brane of  the  nose,  the  principal  disease  to  rule  out  is  tertiary  syphilis.  The 
differences  between  the  two  conditions  may  be  tabulated  as  follows: 

1 .  In  the  neighborhood  of  a  syphilitic  ulceration  there  is  an  intense  in- 
flammatory reaction  of  the  mucous  membrane.  There  is  no  inflammation 
about  a  tubercular  ulceration. 

2.  Sjq^hilis  attacks  by  preference  the  bony  framework  of  the  nasal  cavity. 
Tuberculosis  selects  the  cartilage  of  the  septum. 

3.  Accompanying  the  bony  caries  of  syphilis  there  is  a  marked  stench. 
There  is  seldom  any  odor  in  tuberculosis  of  the  nasal  cavity. 

4.  As  a  rule,  in  syphilis  of  the  nose  there  is  headache  or  neuralgia  of  some 
of  the  neighboring  branches  of  the  fifth  nerve.  In  tuberculosis  there  is 
rarely  any  pain. 

A  piece  of  tissue  may  be  removed  for  microscopical  examination,  but  in 
such  cases  it  is  often  very  hard  to  distinguish  syphilis  from  tuberculosis. 
Giant-cells  may  be  present  in  both  conditions.     The  failure  to  find  giant- 


TUBERCULOSIS   OF   NOSE,    MOUTH,    AND    PHARYNX. — MOSHER.  45 

cells  with  central  caseation,  and  the  finding  of  an  endarteritis,  speak  for 
syphilis.  The  only  positive  proof  of  tuberculosis  is  the  finding  of  baciUi. 
The  finding  of  bacilli,  however,  is  generally  very  difficult.  When  the  diag- 
nosis of  the  nature  of  the  nasal  condition  remains  in  doubt,  it  may  be  made 
clear  by  the  use  of  iodid  of  potash  or  the  injection  of  tuberculin. 

At  times  other  conditions  besides  s^'philis  must  be  ruled  out  in  making  a 
diagnosis.  For  instance,  the  presence  of  abundant  granulation  tissue  calls 
for  the  elimination  of  malignant  disease,  especially  sarcoma.  A  foreign  body 
in  the  nose  also  may  cause  a  growi:h  of  granulation  tissue.  Malignant 
disease  can  be  differentiated  by  the  microscope.  The  finding  of  a  foreign 
body  and  its  removal  are  followed  by  the  disappearance  of  the  granulations. 
This  makes  the  diagnosis  clear. 

Prognosis. — Tuberculosis  of  the  nasal  mucous  membrane,  as  a  rule, 
goes  slowly  and  steadily  onward.  For  a  time  it  may  be  made  to  heal,  but 
it  generally  breaks  out  anew. 

Treatment. — The  best  treatment  is  the  radical  removal  of  the  focus. 
This  is  often  difficult,  because  the  lesion  which  can  be  seen  by  the  eye  is 
surrounded  by  microscopical  tubercles,  which  cannot  be  seen.  These  lead 
to  rapid  recurrence.  In  those  cases  where  there  is  a  tubercular  tumor,  the 
body  of  the  gro\\i:h  may  be  snared  off.  After  this  is  accomplished  the  base 
of  the  tumor,  and  a  generous  amount  of  the  surrounding  mucous  membrane, 
should  be  removed  with  a  curette.  The  curette  is  the  most  useful  instrument 
for  dealing  with  tubercular  manifestations  in  the  nose.  When  much  tissue 
is  to  be  destro5^ed,  thorough  work  can  be  done  only  under  an  anesthetic. 
For  small  or  disseminated  foci,  heated  air,  the  galvanocautery,  or  lactic  acid 
may  be  employed. 

Lactic  acid  is  the  agent  most  commonly  used.  Some  writers  advise 
rubbing  in  the  concentrated  solution.  Others  place  tampons  in  the  nasal 
cavity  saturated  with  an  80  per  cent  solution.  The  tampons  are  left  in 
place  three  hours.  A  slough  forms  on  the  diseased  area,  but  the  healthy 
mucous  membrane  is  only  whitened,  it  is  not  cauterized.  On  the  second  day 
the  slough  caused  by  the  first  application  is  removed,  and  the  treatment  is 
repeated.  This  is  carried  out  for  a  week.  Heated  air  can  be  used  only  in 
the  anterior  part  of  the  nose.  On  this  account  one  writer,  Hollander,  has 
split  the  nose,  cauterized  it,  and  sewed  the  incision  together  again.  In  this 
procedure  there  is  danger  of  tuberculosis  appearing  in  the  incision. 

General  treatment  is  just  as  important  in  tuberculosis  of  the  nasal  cavity 
as  in  the  treatment  of  tuberculosis  of  other  parts  of  the  body.  Wherever 
there  is  a  primary  tubercular  lesion  of  the  nasal  cavity,  it  would  seem  that 
the  use  of  tuberculin  should  have  a  special  field.  It  is  probable  that  many 
cases  of  tuberculosis  of  the  nasal  mucous  membrane  are  overlooked.  Leprosy 
often  begins  in  the  nose  in  small  yellow  tubercles  or  vesicles.     These  are 


46  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

found,  on  examination,  to  be  almost  pure  cultures  of  the  bacillus  of  leprosy. 
In  one  case  which  came  under  my  observation  there  were  but  three  such 
small  lesions  in  the  nose,  and  they  were  almost  overlooked.  In  this  case, 
however,  the  bacilli  had  been  sent  over  the  body  and  had  caused  marked 
lesions  on  the  patient's  legs.  There  is  no  apparent  reason  why  the  tubercle 
bacillus  from  a  small  lesion  in  the  nasal  mucous  membrane  could  not  follow 
the  same  course. 

The  Second  Form  of  Nasal  Tuberculosis. 

The  first  form  of  nasal  tuberculosis  which  has  just  been  spoken  of  is 
characterized  by  infiltration  and  ulceration.  The  second  form  of  tuber- 
culosis of  the  nasal  cavity  is  characterized  by  tumor  formation  and  by  a 
tendency  to  spread.  The  first  form  is  a  local  affection;  the  second  is  part 
of  a  general  infection  or  soon  causes  a  general  affection.  This  form  often 
leads  to  tuberculosis  of  the  pharynx. 

This  type  is  malignant,  and  soon  ends  in  death.  General  tuberculosis 
can  be  demonstrated  so  readily  that  the  diagnosis  of  the  nature  of  the 
pathological  process  in  the  nose  is  easy.  The  prognosis  is  always  bad.  In 
the  advanced  cases  only  palliative  treatment  with  menthol,  orthoform,  or 
cocain  is  advisable. 


TUBERCULOSIS  OF  THE  MOUTH. 

In  tuberculosis  of  the  mouth  the  lesions  may  be  found  on  the  lips,  the 
cheeks,  the  gums,  the  alveolar  process,  the  hard  or  the  soft  palate,  or  the 
tongue.  It  is  comparatively  rare  to  find  a  tubercular  lesion  involving  but  one 
of  the  structures  of  the  mouth.     Such  cases  form  a  class  by  themselves. 

The  Forms  of  Tuberculosis  of  the  Mouth. — Tubercular  lesions  of  the 
mouth  may  be  divided  according  to  the  pathological  changes;  according  to 
their  mode  of  development;  and  according  to  their  clinical  course. 

1.  Classified  according  to  the  pathological  changes,  there  are  found 
nodular  infiltration,  superficial  ulceration,  deep  ulceration,  necrosis  of  bone, 
chronic  abscess,  and  tumor. 

2.  Classified  according  to  development,  there  are  the  ascending  and  the 
descending  types.  The  ascending  type  is  caused  by  inoculation  and  is  purely 
local.  The  descending  type  is  caused  by  infection  through  the  blood  or 
through  the  lymph-channels.     With  this  there  is  often  systemic  infection. 

3.  Classified  according  to  their  clinical  course,  tubercular  infections  of  the 
mouth  are  benign  or  malignant.  The  lesions  in  the  ascending  form  are 
sluggish  in  their  growth,  and  so  are  benign.  In  the  descending  tuberculosis 
arising  from  miliary  deposits,  or  from  infection  from  within,  the  lesions  are 
more  active.     Such  lesions  are  classed  as  malignant. 


TUBERCULOSIS  OF  NOSE,  MOUTH  AND  PHARYNX. — MOSHER.      47 

4.  Classified  according  to  the  origin  of  the  infection,  tubercular  lesions  of 
the  mouth  are  either  primary  or  secondary.  In  primary  tuberculosis  of  the 
mouth  the  infection  enters  at  the  point  of  the  lesion.  In  secondary  tuber- 
culosis the  lungs  or  the  blood-current  furnish  the  infection.  Secondary 
tuberculosis  of  the  mouth  is,  therefore,  a  part  of  a  general  tuberculosis. 

Etiology  of  Tuberculosis  of  the  Mouth. — There  are  many  cases  on 
record  of  tuberculosis  of  the  tongue.  In  all,  the  history  of  the  disease  is 
generally  the  same.  The  lesion  begins  with  a  slight  injury  of  the  mucous 
membrane,  which  refuses  to  heal,  and  in  time  is  supplanted  by  a  typical 
tubercular  ulceration.  The  bacilli,  one  would  think,  would  be  most  liable 
to  effect  their  entrance  at  the  point  of  injuiy,  but  there  is  a  tendency  among 
some  writers  to  look  for  a  distant  source  for  the  infection.  They  maintain 
that  the  infection  comes  from  a  bronchial  gland  which  has  become  infected 
from  the  lungs,  or  that  it  comes  from  a  latent  tuberculosis  of  the  faucial  or 
phary^ngeal  tonsils,  or  even  from  bacilh  harbored  in  a  diseased  tooth.  This 
seems  a  bit  fanciful,  although  it  is  undoubtedly  true  that  the  chief  sources  of 
infection  in  tuberculosis  are  the  lymph-  and  the  blood-currents.  The  tongue 
is  protected  by  its  thick  coating  of  epithelium,  and  the  mouth  by  its  mucous 
membrane.  The  unbroken  epithelium  of  the  tongue  and  the  intact  mucous 
membrane  of  the  mouth  are  not  easily  infected.  In  cases  of  pulmonary 
tuberculosis  both  are  continually  bathed  in  infected  sputum,  yet  tubercular 
lesions  of  the  tongue  or  of  the  mucous  membrane  of  the  mouth  are  the  ex- 
ception, not  the  rule.  That  trauma  plays  an  important  part  in  producing 
tubercular  lesions  of  the  mouth  is  shown  by  the  fact  that  tuberculosis  of  this 
region  is  three  times  as  frequent  in  men  as  in  women.  Men  naturally  subject 
their  mouths  to  more  trauma  than  women,  and,  as  a  rule,  take  less  care  of 
their  teeth.  Another  argument  along  the  same  line  is  the  fact  that  tubercular 
ulcerations  are  often  seen  about  ragged  and  carious  teeth. 

The  Course  of  Tuberculosis  of  the  Mouth. — Tuberculosis  of  the  lips, 
the  cheeks,  the  gums,  the  hard  palate,  or  the  tongue  pursues  a  slow  course 
and  is  comparatively  non-malignant.  Tubercular  ulcers  of  the  mouth  ad- 
vance slowly  and  seldom  completely  heal.  A  few  cases  have  been  known  to 
heal  spontaneously,  and  a  small  percentage  can  be  made  to  heal  by  treat- 
ment. They  are  a  source  of  but  little  discomfort.  Unless  they  are  painful 
and  so  interfere  with  swallowing,  they  have  but  slight  influence  upon  the 
course  of  a  case  of  tuberculosis  of  the  lungs.  It  should  be  remembered  that 
tuberculosis  of  the  tongue  may  at  times  be  very  malignant. 

Diagnosis. — There  is  a  natural  tendency  to  regard  every  ulceration  in 
the  mouth  and  pharynx  of  a  tubercular  person  as  tubercular.  It  not  in- 
frequently happens,  however,  that  a  person  having  tuberculosis  contracts 
syphilis.  In  such  a  case  the  lesions  of  both  diseases  may  appear  in  the  mouth 
or  in  the  nose  side  by  side.    The  great  white  plague  and  the  great  red  plague 


48  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

are  seen  together.  After  the  healing  of  an  extensive  tubercular  ulceration 
the  contraction  of  the  scar  tissue  may  distort  and  fissure  the  tongue  in  the 
same  manner  as  happens  in  syphiUs.  A  fissured  tongue,  therefore,  is  not 
always  a  sign  of  previous  s^^hilis.  Where  the  tubercular  ulceration  is 
accompanied  by  an  abundant  overgrowth  of  tissue,  the  resulting  lesion  may 
look  very  much  hke  carcinoma. 

Lesions  of  the  mucous  membrane  of  the  mouth  are  so  readily  inspected 
that  tubercular  lesions  of  the  lips  or  of  the  tongue,  for  instance,  can  be 
thoroughly  studied,  and  their  characteristics  determined.  In  discussing 
tuberculosis  of  the  mouth,  therefore,  the  description  of  the  typical  tuber- 
cular ulcer  finds  its  most  fitting  place.  Excluding  isolated  cases  of  tubercular 
tumor  or  abscess  there  exists  in  tuberculosis  of  the  mouth  a  uniform  local 
lesion.  This  consists  in  a  pale,  superficial  ulceration,  which  is  without  in- 
flammatory areola.  The  edges  are  irregular,  beveled,  or  undermined.  The 
ulcer  spreads  at  the  sides.  A  sticky,  dirty  white  secretion  covers  it.  When 
this  is  removed,  the  base  of  the  ulcer  is  seen  to  be  nodular.  Scattered  over 
the  face  of  the  ulcer  and  upon  its  margin  there  are  soft,  small,  red  granu- 
lations, interspersed  with  yellow  or  gray  spots  the  size  of  a  pinhead.  These 
yellow  spots,  the  spots  of  Trelat,  may  be  seen  also  upon  the  mucous  mem- 
brane, adjacent  to  the  ulceration.  All  these  signs  are  not  present  in  every 
tubercular  ulceration,  but  they  are  in  the  majority.  In  every  instance  the 
diagnosis  should  be  confirmed  by  microscopical  findings,  and  in  obscure 
cases  by  the  inoculation  of  guinea-pigs.  The  findings,  in  sections,  of  giant- 
cells,  together  with  caseous  material,  is  almost  certain  proof  of  tuberculosis. 

The  Laboratory  Methods  of  Confirming  the  Diagnosis  of  Tuberculosis. — 

1.  The  detection  of  tubercle  bacilli:  (a)  By  the  microscope;  or  (6)  by 
the  inoculation  of  guinea-pigs. 

2.  The  detection  in  stained  specimens  of  the  histological  structures  of  the 
tubercle. 

1.  The  Detection  of  Bacilli. — (a)  Owing  to  the  frequent  presence  of  bacilli 
in  the  mouths  of  tubercular  patients,  the  examination  of  swabs  made  from 
a  suspected  ulcer  is  of  no  value.  The  proper  method  of  procedure  is  as 
follows:  The  ulcer  should  be  cleaned  and  cocainized,  and  then  curetted  or  a 
piece  removed.  The  curettings  are  thoroughly  rubbed  between  two  slides 
or  cover-glasses  until  thin  smears  are  obtained.  The  presence  of  tubercle 
bacilli  in  the  smears  should  be  substantiated  by  the  finding  of  baciUi  within 
the  small  clumps  of  cells  which  the  rubbing  has  failed  to  separate. 

If  a  piece  of  tissue  is  removed,  this  is  hardened  and  stained  for  tubercle 
bacilli. 

(b)  The  Inoculation  of  Guinea-pigs. — This  method  is  called  for  only  when 
other  means  fail. 

2.  The  Detection  of  the  Histological  Structure  of  the  Tubercle. — The  histo- 


TUBERCULOSIS    OF    NOSE,    MOUTH,    AND    PHARYNX. — MOSHER.  49 

logical  structure  of  the  miliaiy  tubercle  can  generally  be  found  in  portions 
of  the  tissue  which  have  been  removed,  sectioned,  and  stained.  No  one 
structure  in  itself  is  diagnostic.  However,  the  presence  together  of  giant- 
cells  and  caseation  may  be  taken  as  sufficient  proof  of  tuberculosis  w'hen  the 
structure  is  not  wholly  t}'pical.     Often  it  is  very  hard  to  find  bacilli. 

Subjective  Symptoms. — ^Tubercular  lesions  involving  the  lips,  the  gums, 
or  the  tongue  may  exist  for  a  considerable  time  before  the  patient  becomes 
aware  of  their  presence.  There  is  so  Httle  pain  that  an  ulcer  may  attain 
considerable  depth  \\ithout  making  itself  felt.  This  is  in  strildng  contrast 
to  tubercular  lesions  of  the  phaiynx  or  of  the  larynx.  The  ulcerations  have 
but  sHght  odor.  Tubercular  lesions  of  the  tongue  may  at  times  be  very 
painful. 

Tesions  of  the  gum.s  or  the  hard  palate,  however,  rarely  give  pain.  Where 
the  lesions  of  the  mouth  develop  in  the  course  of  a  severe  general  infection, 
they  rapidly  extend  to  the  tonsils,  the  soft  palate,  and  the  pharynx.  In 
these  cases  there  is  marked  pain  on  swallowing. 

Objective  Symptoms. — Glandular  involvement  may  or  may  not  be 
present.  Excluding  the  isolated  cases  in  which  the  lesion  consists  of  a  tuber- 
cular tumor  or  a  tubercular  abscess,  the  typical  tubercular  ulceration  wliich 
has  just  been  described  is  present. 

Treatment. — A  tubercular  tumor  should  be  removed,  its  base  curetted 
and  treated  v/ith  lactic  acid.  A  tubercular  abscess  should  be  opened,  and 
then  treated  in  the  same  manner.  A  tubercular  ulcer  should  be  curetted  and 
then  treated  with  lactic  acid.  Any  source  of  irritation,  like  a  decayed 
tooth,  should  be  removed. 

TUBERCULOSIS  OF  THE  PHARYNX. 

The  structures  in  the  pharj^nx  which  are  subject  to  tuberculosis  are  the 
faucial  tonsils,  the  lateral  folds  of  the  pharynx,  the  uvula,  the  soft  palate, 
the  posterior  pharyngeal  wall,  the  phaiyngeal  tonsil,  and  the  lymphoid 
tissue  about  the  mouths  of  the  Eustachian  tubes.  Tuberculosis  of  the 
tonsil  is  by  far  the  most  important.  I  shall  not  deal  with  tuberculosis  of  the 
different  structures  of  the  pharynx  in  their  anatomical  order,  but  shall  deal 
with  the  less  important  forms  first,  and  the  most  important,  that  is,  tonsillar 
tuberculosis,  last. 

The  Frequency  of  Tuberculosis  of  the  Pharynx. — Frankel  found, 
in  50  autopsies  on  tubercular  patients,  that  the  pharynx  was  involved  10 
times.  In  3  of  these  cases  the  pharyngeal  tonsil  was  involved  alone,  in  2 
the  lymphoid  tissue  about  the  Eustachian  tubes.  In  the  other  5  both  regions 
were  involved  together.  Wendt  maintains  that  in  tuberculosis  of  the  pharynx 
there  is  seldom  a  complication  of  active  disease  of  the  middle  ear.  Often, 
however,  in  these  cases  the  patient  complains  of  a  subjective  sensation  of 
fullness  in  the  ear,  with  pain  radiating  from  the  ear  on  swallowing. 


50  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

The  Course  of  Tuberculosis  of  the  Pharynx. — It  is  rare  to  have 
tuberculosis  of  the  pharynx  result  from  direct  extension  of  a  tubercular 
process  in  the  nose.  When  tuberculosis  of  the  nose  and  of  the  pharjTix 
exist  together,  they  are  both  usually  a  part  of  a  general  tuberculosis.  Tuber- 
culosis of  the  phar}'nx  is  seldom  primary.  Generally,  the  infection  of  this 
region  is  the  result  of  the  flood  of  sputum  which  is  poured  out  by  the  lungs. 
In  these  trying  cases  the  greater  part  of  the  pharynx  may  become  excessively 
nodular  and  ulcerated.     Fortunately  such  patients  soon  die. 

Tuberculosis  of  the  Uvula,  the  Soft  Palate,  the  Pillars,  and  the 
Posterior  Pharyngeal  Wall. 

The  earliest  signs  of  tuberculosis  of  the  uvula,  the  soft  palate,  the  pillars, 
or  of  the  posterior  pharyngeal  wall  is  the  appearance,  in  some  part  of  the 
mucous  membrane,  of  a  pale,  edematous  area.  Within  this  small  area,  sub- 
mucous yellow  spots  the  size  of  a  pinhead  can  be  made  out.  The  yellow 
spots  or  tubercles  break  down  and  coalesce  into  an  ulcer  with  characteristic 
worm-eaten  edges.  The  ulcerations  often  become  deep,  but  their  margins 
always  retain  the  typical  granular  or  tubercular  appearance. 

Prognosis. — Where  the  pharynx  is  involved  to  only  a  slight  extent,  the 
tubercular  lesion  does  not  make  the  prognosis  bad.  Where,  however,  there  is 
extensive  ulceration,  the  patient  has  much  difficulty  in  swallowing.  On 
this  account  the  prognosis  becomes  very  poor. 

Treatment. — Where  the  ulcerations  of  the  soft  palate  or  of  the  pharyn- 
geal wall  are  small,  they  may  be  curetted  or  they  may  be  swabbed  with 
lactic  acid.  When  they  are  extensive,  orthoform  or  cocain  must  be  used 
freely  in  order  to  enable  the  patient  to  swallow.  If  the  patient  is  tolerant, 
he  may  be  fed  by  the  stomach-tube.  In  most  cases,  however,  this  procedure 
is  too  painful. 

Tuberculosis  of  the  Tonsil. 

Frequency. — Of  the  different  parts  of  the  upper  respiratory  tract,  the 
faucial  tonsil  is  the  most  liable  to  tuberculosis.  By  far  the  greater  number 
of  cases  are  secondar}\  In  pulmonary  tuberculosis  the  tonsils  are  constantly 
bathed  with  sputum.  Wood  reports  that  in  136  cases  of  pulmonary  tuber- 
culosis 94,  or  69  per  cent.,  were  found  to  be  infected.  Various  investigators 
agree  that  primary  tuberculosis  of  both  the  faucial  and  the  pharyngeal 
tonsil  occurs  in  5  per  cent,  of  cases.  Wood  believes  that  5  per  cent,  of  all 
children  have  tubercular  tonsils. 

Course. — The  tubercular  lesion  in  the  tonsil  may  remain  localized  or  the 
lesion  may  heal.  In  a  great  majority  of  cases  the  infection  travels  to  the 
cervical  glands.  Having  reached  the  glands,  it  travels  from  one  gland  to 
another.  It  is  doubtful  if  the  infection  ever  directly  reaches  the  pleura 
from  the  glands.     From  the  glands,  however,  the  infection  may  reach  the 


TUBERCULOSIS  OF  NOSE,  MOUTH,  AND  PHARYNX. — MOSHER.      51 

lymph-current  and  through  this  the  general  circulation,  by  way  of  the  venous 
system,  and  so  produce  a  miUary  tuberculosis.  This  happening,  however, 
is  rare. 

There  are  two  forms  of  tuberculosis  of  the  tonsils — primary  tuberculosis 
and  secondaiy  tuberculosis. 

Secondary  Tuberculosis  of  the  Tonsils. — Secondaiy  tuberculosis 
of  the  tonsils  is  more  common  than  primary  tuberculosis,  but  it  is  less  im- 
portant. I  will  speak  of  secondary  tuberculosis  of  the  tonsils  first.  Secon- 
dary tuberculosis  of  the  tonsils  is  divided  into  two  forms: 

1 .  Acute  tonsillar  tuberculosis. 

2.  Chronic  tonsillar  tuberculosis. 

Acute  Tonsillar  Tuberculosis. — Acute  tonsillar  tuberculosis  is  a  part  of  a 
miliary  tuberculosis,  or  it  is  a  metastatic  process  occurring  in  the  last  stages 
of  pulmonary  tuberculosis. 

Diagnosis. — In  the  earliest  stages  the  mucous  membrane  of  the  tonsil 
becomes  edematous  and  pale.  Tubercles  are  seen  beneath  the  mucous 
membrane.  These  presently  break  down  and  form  the  tjpical  tubercular 
ulcer.     This  often  causes  great  destruction  of  tissue. 

Chronic  Tonsillar  Tuberculosis. — Chronic  tonsillar  tuberculosis  is  always 
latent  and  without  symptoms.  The  majority  of  cases  are  due  to  infec- 
tion from  sputum.  It  has  been  found  that  the  larger  the  amount  of  the 
sputum,  the  more  often  are  the  tonsils  infected.  Wood's  statistics  show  that 
considerably  over  half  of  the  cases  of  pulmonary  tuberculosis  develop  secon- 
dar)^  tuberculosis  of  the  tonsils.     Such  cases  run  a  mild  course. 

Primary  Tuberculosis  of  the  Tonsils. — In  primary  tuberculosis  of 
the  tonsils  the  infection  may  come  through  the  blood  from  a  distant  focus, 
but,  as  a  rule,  it  comes  from  the  air-current  or  from  food.  Primary  tuber- 
culosis of  the  tonsils  occurs  in  5  per  cent,  of  all  tonsils.  Some  of  these  cases 
are  instances  of  bovine  tuberculosis,  but  just  how  frequently  bovine  tuber- 
culosis of  the  tonsils  occurs  has  not  been  worked  out. 

Pharyngitis  Lateralis. — Pharyngitis  lateraUs  consists  in  the  formation 
of  a  small  elongated  tonsil  over  the  surface  of  the  stylophar}'ngeus  muscle 
as  it  runs  downward  behind  and  parallel  with  the  posterior  pillar.  In  this 
hypertrophy  of  the  lateral  folds  of  the  pharynx  there  is  not  only  increase  of 
the  lymphoid  tissue,  but  there  is  also  the  formation  of  crj^ts  and  follicles.  A 
true  tonsil  in  miniature,  therefore,  exists  on  the  surface  of  the  lateral  folds. 
Tuberculosis  of  the  lateral  tonsils  is  the  same  in  all  respects  as  tuberculosis 
of  the  faucial  or  phaiyngeal  tonsil.  Tuberculosis  of  the  lateral  tonsils  is 
almost  always  secondary.  It  is  recognized  by  the  presence  of  tubercles  or  by 
the  typical  tubercular  ulceration. 

The  Drainage  of  the  Tonsils. — The  faucial  tonsil  drains  first  into 
the  superficial  glands  of  the  neck  and  then  into  the  deep  anterior  chain  of  the 


52  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

cervical  glands.  The  pharyngeal  tonsil  drains  into  the  retropharyngeal  and 
suboccipital  glands,  and  from  here  into  the  deep  posterior  cervical  glands. 
These  glands  are  placed  behind  the  posterior  border  of  the  sternocleidomas- 
toid muscle.  It  has  usually  been  held  that,  by  anastomoses  with  retro- 
sternal, peritracheal,  and  bronchial  glands,  infection  could  travel  from  the 
cervical  glands  to  the  pleura  or  to  the  lungs.  It  is  doubtful  if  this  often 
happens.  The  pharyngeal  tonsil  is  situated  at  the  entrance  to  the  respir- 
atory tract,  so  that  inspired  air  comes  directly  in  contact  with  it.  The 
faucial  tonsils  are  placed  at  the  entrance  to  the  digestive  tract,  and  come  in 
contact  more  with  food  than  with  the  inspired  air. 

The  tonsil  is  a  lymph-gland  placed  on  the  surface  of  the  body.  It 
is  a  very  old  fact  that  the  bronchial  glands  will  absorb  foreign  bodies 
like  particles  of  dust.  It  is  not  surprising,  therefore,  that  the  tonsils  will 
do  the  same  thing.  Bacteria  are  not  absorbed  so  readily.  The  epithelium 
of  the  cr}qjts  seems  to  be  the  barrier  to  the  entrance  of  bacteria.  As  soon 
as  this  is  destroyed,  the  door  is  opened  to  infection.  The  comparative  im- 
munity of  the  tongue  to  tubercular  infection  is  due  to  the  thick  layer  of 
epithelium  v/hich  covers  it.  The  same  reasoning  would  apply  to  the  crj^pts 
of  the  tonsils.  When  this  is  thick  or  unbroken,  the  tonsils  should  be  the  least 
liable  to  infection.  I  believe  that  this  is  the  case.  Of  late,  the  tendency 
has  been  to  consider  the  amount  of  the  bacterial  dose  rather  than  any  mech- 
anical barrier  offered  by  the  tissues,  the  chief  factor  in  determining  whether 
the  tonsils  are  to  be  infected  or  not.  All  that  is  necessary,  according  to  this 
view,  for  the  production  of  tuberculosis  of  the  tonsils,  is  to  bring  them  in  con- 
tact with  a  sufficient  number  of  bacilli  to  overcome  the  resistance  of  the 
tissues. 

I  feel  that  the  thickness  of  the  epithelium  which  lines  the  crypts  has 
much  to  do  with  the  susceptibility  of  the  tonsil  to  infection.  At  birth,  the 
epithelium  lining  the  crypts  is  relatively  thick,  but  as  soon  as  the  germinal 
centers  become  active,  they  send  off  showers  of  lymphocytes.  These  pour 
upon  the  epithelium  of  the  crypts,  and  in  some  places  they  tear  it  into  finger- 
like prolongations,  while  in  other  places  they  scatter  the  cells  so  that  but 
a  very  thin  layer  remains  surrounding  the  follicle.  This  thinning  of  the 
epithelium  of  the  crypts  begins  at  six  months  and  lasts  through  childhood. 
In  adult  life  the  activity  of  the  germinal  centers  is  over,  and  the  epithelium 
of  the  crypts  again  becomes  thick.  In  addition,  the  body  of  the  tonsil  gradu- 
ally becomes  fibrous  and  the  tonsil  shrinks  in  size.  At  the  time  that 
the  epithelium  of  the  crypts  is  thinnest,  that  is,  in  childhood,  the  tonsils  are 
oftenest  infected.  It  is  at  this  period  that  tonsillitis  is  most  frequent  and  en- 
larged glands  most  common.  On  theoretical  grounds  one  might  argue  that 
the  tonsils  in  childhood  should  be  least  liable  to  infection,  owing  to  the  pro- 
tective action  of  the  lymphocytes.    They  are  made  in  such  quantities  by 


TUBERCULOSIS    OF    NOSE,    MOUTH,    AND   PHARYNX. MOSHER.  53 

the  germinal  centers  that  it  would  seem  as  if  they  might  produce  a  liberal 
supply  of  protective  vaccine.  It  may  be  that  their  stay  in  the  tonsillar  tissue 
is  too  short  for  this  to  be  accomplished,  because  they  tear  their  way  so  quickly 
through  the  epithelium  to  become  inert  in  the  crypts.  In  a  submerged 
gland,  like  a  gland  of  the  neck,  this  does  not  happen. 

The  Liability  to  Systemic  Infection  from  Tuberculosis  of  the 
Tonsils. — If  a  given  part  of  the  body  is  inoculated  with  tuberculosis,  a  local 
lesion  develops  at  the  point  of  infection.  From  this  point  the  infection  is 
carried  to  the  nearest  set  of  lymph-nodes.  The  tubercular  bacilli  are 
arrested  here  until  the  barrier  is  destroyed.  When  it  is  overcome,  the  infection 
proceeds  to  the  next  chain  of  glands,  and  finally  reaches  the  venous  system 
by  way  of  the  lymphatics.  The  tonsil  is  in  reality  a  lymph-gland,  but  slightly 
differentiated  from  other  lymph-glands.  It  does  not  seem,  however,  to  have 
the  same  stopping  power  that  the  other  glands  possess.  For  instance, 
it  has  been  proved  experimentally  that  the  tubercle  bacillus  will,  after  a  few 
days,  pass  directly  through  the  tonsil  to  the  tonsillar  gland  of  the  neck, 
•without  leaving  behind  any  microscopical  change  in  the  tonsil.  A  very 
large  majority  of  enlarged  cervical  glands,  perhaps  80  per  cent.,  are  tuber- 
culous, and  the  infection  comes  from  the  tonsil. 

It  has  been  held  that  infection,  once  started  in  the  cervical  lymphatics, 
may  continue  downward,  gland  by  gland,  until  the  apices  of  the  pleura 
are  infected  by  extension  and  contact.  Recent  anatomical  studies  seem  to 
show  that  this  can  occur  but  rarely.  There  is  no  gland  constantly  present 
in  contact  with  the  apex  of  the  lung.  Clinical  obsei-vation  bears  out  this 
anatomical  finding.  Tuberculosis  of  the  cervical  glands  is,  as  a  rule,  a  local- 
ized affection,  and  does  not  ordinarily  lead  to  tuberculosis  of  the  lungs. 
When  tuberculosis  of  the  lungs  does  take  place  from  the  cervical  glands, 
the  infection  occurs  through  the  lymphatic  trunks  and  the  venous  system. 
In  children  the  infection  of  the  lungs,  and  hence  the  infection  of  the  bronchial 
glands,  takes  place  in  most  instances  through  the  aspiration  of  tubercle 
bacilli  into  the  bronchi.  A  descending  tuberculosis  of  the  cervical  glands 
may  be  present  incidentally.  The  aspirated  bacilli  may  come  from  the  air, 
but  more  often  they  come  from  the  mouth,  where  they  have  gained  access 
by  the  food  or  by  contact  (Grober). 

Treatment. — For  practical  purposes  the  crypts  of  the  tonsil  may  be 
considered  as  running  completely  through  the  body  of  the  tonsil  to  its  re- 
taining capsule.  Therefore  in  removing  tonsils  where  they  are  the  source 
of  chronic  infection,  no  operation  is  to  be  thought  of  except  complete  removal 
of  the  tonsil  and  its  capsule  by  dissection.  Where  the  tonsils  give  trouble 
merely  by  obstructing,  less  thorough  removal  may  in  certain  cases  be  con- 
sidered. In  all  cases  of  cervical  adenitis  the  tonsils  should  be  thoroughly  re- 
moved as  the  first  step  in  the  treatment.  The  only  exception  to  this  rule 
is  the  presence  of  advanced  pulmonary  tuberculosis. 


SECTION  III. 
Surgery  and  Orthopedics  (^Continued). 


SECOND  DAY. 

Tuesday,  September  29,  1908. 

TUBERCULOSIS  OF  THE  LYMPHATIC  GLANDS,  THE   BREAST, 
PLEURA,  AND  LUNGS. 


The  Section  was  called  to  order  at  half-past  nine  by  the  President,  Dr. 
Charles  H.  Mayo. 


TUBERCULOSIS   OF   THE   CERVICAL   LYMPH-NODES 
REPORT  ON  275  CASES  TREATED  BY  RADICAL 
EXTIRPATION. 

By  Charles  N.  Dowd,  M.D., 

New  York. 


Tuberculosis  of  the  neck  lymphatics  holds  a  unique  position  in  surgery. 
It  is  the  only  common  form  of  tubercular  infection  which  can  be  removed 
surgically  without  injuring  a  single  important  structure  and  without  serious 
disfigurement. 

It  is  far  otherwise  with  those  forms  of  tuberculosis  which  are  located  in 
the  bones  and  joints,  in  the  abdominal  organs,  and  in  the  lungs.  The  radical 
removal  of  the  diseased  foci  from  these  localities  would  be  most  desirable, 
but  is  seldom  possible  without  important  injury  to  surrounding  structures. 

It  seems  a  little  strange  that  a  locality  so  filled  with  important  structures 
as  the  neck  is  should  offer  so  favorable  a  site  for  the  radical  removal  of 
tuberculosis.     There  are  two  elements  to  explain  this: 

L  The  important  structures  are  in  the  soft  parts,  and  can  usually  be 
separated  from  the  diseased  tissues  without  injury. 

2.  The  infection  here  is  almost  uniform  in  its  development,  first  showing 

54 


TUBERCULOSIS   OF   THE   CERVICAL    LYMPH-NODES. — DOWD. 


55 


itself  in  the  subparoticl  nodes  and  then  spreading  in  the  lymphatics  down- 
ward and  backward,  and  occasionally  forward.  The  dissection,  therefore, 
can  be  carried  on  in  a  perfectly  uniform  and  definite  manner,  and  can  be 
done  satisfactorily  in  the  stage  of  the  disease  in  which  the  majority  of  the 
cases  are  now  referred  to  the  surgeon. 

On  the  other  hand,  this  form  of  tuberculosis  is  not  especially  well  suited 
for  hygienic,  climatic,  and  medicinal  treatment.  The  reports  from  institu- 
tions where  these  forms  of  treatment  are  used,  and  conversation  with  their 
physicians,  indicate  that  patients  \\dth  this  form  of  tuberculosis  do  not  show 
as  much  improvement  as  some  of  the  others  do,  and  that  they  are  often 
referred  to  the  surgeon. 

I  wish  to  ask  your  attention  to  a  study  of  275  cases  of  this  illness  operated 
upon  in  St.  Mary's  Hospital  for  Children,  in  the  General  Memorial  Hospital, 
and  in  private  practice  during  the  last  fourteen  years.  Nearly  all  the  oper- 
ations were  done  by  the  writer,  a  few  of  them  by  other  members  of  the  hos- 
pital staff.  The  technic  has  been  given  elsewhere.  In  each  case  the  effort 
to  remove  all  the  diseased  tissue  has  been  made.  The  after-histories  of  the 
patients  have  been  very  carefully  followed.  Nurses  have  been  employed 
for  the  purpose,  under  a  special  fund,  and  they  have  brought  the  patients 
back  to  the  hospital  for  observation,  and  the  observations  have  been  re- 
newed year  after  year. 

The  record  of  obseivations  is  as  follows: 


16  v/ere  followed 

more  1 

than  10  years 

8     ' 

into  the  10th  year 

4     ' 

" 

'      9th     " 

4     ' 

" 

"      8th     " 

8     ' 

<( 

'      7th     " 

14     ' 

<( 

'      6th     " 

16     ' 

ti 

'      5th     " 

26     ' 

(1 

'      4th     " 

28     ' 

ti       t 

'      3d      " 

59     ' 

11       i 

'      2d       " 

42     ' 

ti 

'      1st      " 

50  Mere  not  traced,  or  have  had  their  operations  very  recently. 


The  results  are  as  follows: 

Among  54  'patients  observed  jar  periods  of  from  jive  to  thirteen  and  a  half 
years,  53  are  apparently  cured;  that  is,  they  are  in  vigorous  health,  having 
either  no  palpable  neck  nodes  or  only  such  small,  hard  ones  as  are  believed 
to  be  hyperplastic  and  not  tubercular.  They  are  also  free  from  evidence  of 
tuberculosis  in  any  other  part  of  the  body. 

One  patient,  a  woman  of  thiity-six,  who  had  had  operations  on  both 
sides  of  her  neck,  had  a  hickory-nut-sized  nodule  under  the  upper  part  of 
the  sternomastoid,  and  two  or  three  smaller  ones  below  and  in  front  of  this, 
and  a  tendency  to  cough. 


56  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

The  veiy  satisfactory  condition  indicates  that  those  who  have  passed 
five  years  in  good  health  since  their  operation  need  have  httle  fear  of  serious 
recurrence. 

The  second  group,  of  42  patients,  who  have  been  under  observation 
between  three  and  five  years,  gives  37  apparent  cures,  4  patients  who  have 
had  recurrences  and  still  have  filbert-sized  nodes  in  the  neck,  and  1  death 
from  phthisis. 

Thus,  among  96  patients  followed  for  periods  of  from  three  to  thirteen 
and  a  half  years  are  93  per  cent,  of  apparent  cures,  1  death  from  phthisis, 
and  5  patients  with  recurrent  nodes  from  which  ultimate  cure  may  be 
expected. 

The  group  of  87  cases  followed  from  one  to  three  years  gives  83.8  per  cent, 
of  apparent  cures ;  3  intercurrent  deaths  (2  from  tuberculosis,  1  from  typhoid 
fever) ;  8  patients  with  recurrent  nodes  at  the  time  of  observation,  from  most 
of  whom  an  ultimate  cure  may  be  expected ;  1  persisting  sinus ;  1  syphilitic 
swelling;   1  having  had  recent  operation  for  recurrence. 

In  the  group  of  92  patients  followed  less  than  a  year  there  were  80  (86  per 
cent.)  who  gave  no  evidence  of  tuberculosis  when  last  seen;  4  who  had 
recurrences  in  the  neck  when  examined;  1  who  had  had  a  recent  operation 
for  recurrence  in  the  neck;  1  who  had  tubercular  peritonitis;  1  who  had  a 
syphilitic  swellingin  the  neck.  Five  intercurrent  deaths  occurred  in  this  group 
(1  from  scarlet  fever  and  4  from  tuberculosis);  1  post-operative  death  oc- 
curred from  secondary  hemorrhage  from  the  internal  jugular  vein,  the  only 
operative  fatality  in  the  entire  series  of  275  cases. 

If  we  tabulate  these  cases  according  to  groups  we  have: 

Group     I — 54  cases,  followed  5  to  13§  years — apparent  cures,  98    per  cent. 

11—42     "  "        3  to    5       "  "  "  88 

"       III— 87     "  "         1  to    3       "  "  "  83.8       " 

"       IV— 92     "  "        less  than  a  year        "  "  85.8       " 

We  are  well  aware  that  there  are  some  patients  in  the  list  of  apparent 
cures  who  will  develop  recurrences,  and  that  most  of  those  who  now  have 
recurrences  will  ultimately  be  cured.  It  is  impossible  to  give  a  table  of 
results  with  mathematical  accuracy,  since  the  patients  cannot  all  be  followed 
to  the  ends  of  their  lives,  but  it  is  confidently  believed  that  these  tables 
give  a  very  fair  indication  of  the  value  of  the  method.  They  surely  sub- 
stantiate the  statements  that  the  neck  is  a  particularly  favorable  site  for  the 
surgical  treatment  of  tuberculosis,  and  that  this  operation  is  one  of  the  most 
satisfactory  of  surgical  procedures. 

There  are  numerous  topics  which  might  well  be  considered  about  this 
series  of  cases.  Some  of  them  have  already  been  discussed  in  other  papers, 
others  cannot  be  discussed  now  from  lack  of  space,  but  a  brief  reference  to 
two  topics  may  be  of  value: 


TUBERCULOSIS   OF   THE    CERVICAL   LYMPH-NODES. — DOWD.  57 

1.  Sources  of  infection. 

2.  Operations  for  recurrences. 

1.  Sources  of  Infection. — Tliis  group  of  357  cases  corresponds  closely 
-to  the  group  of  100  cases  previously  reported.  Eighty-one  per  cent,  showed 
the  first  noticeable  infection  in  the  subparotid  nodes,  indicating  infection 
from  the  pharjTix,  tonsils,  or  posterior  part  of  the  mouth.  In  most  of  the 
remaining  cases  the  submental  or  submaxillary  nodes  were  the  first  ones 
involved,  indicating  infection  from  the  teeth,  front  part  of  mouth,  or 
face. 

In  a  few  instances  lupus  spots  on  the  side  of  the  face  or  scalp  gave  infec- 
tions which  traveled  dowTiward  through  the  parotid  group  of  lymphatics. 
In  only  one  instance  was  there  an  ascending  infection  from  the  arm.  This 
involved  the  axillary  lymphatics,  and  at  a  later  time  those  in  the  neck. 

Through  the  courtesy  of  Dr.  Wm.  H.  Park,  Director  of  the  Research 
Laboratory  of  the  New  York  Health  Department,  the  nodes  from  35  cases 
were  examined  by  inoculation  and  subsequent  culture  methods  to  determine 
the  ratio  of  bovine  to  human  type  of  tuberculosis.  The  ultimate  results  on 
12  of  these  cases  are  at  hand:  only  one  was  found  to  be  of  the  bovine 
type,  a  child  whose  infection  began  at  the  age  of  twelve  months.  The 
indications  lead  one  to  believe  that,  in  the  great  majority  of  instances,  the 
infection  comes  from  the  lodgment  of  tubercle  bacilli  in  the  phar3aix  or 
posterior  part  of  the  mouth,  probably  mostly  by  inhalation. 

2.  Recurrences. — Besides  knowing  the  likelihood  of  ultimate  cure, 
physician,  patient,  and  patient's  friends  wish  to  know  the  probability  of 
eradicating  the  disease  at  the  first  operation.  Among  these  275  cases,  46 
have  had  operations  for  recurrences.  Twenty-six  of  them  belonged  to  the 
severe  type  who  have  very  extensive  infections;  some  of  them  had  recur- 
rences either  on  the  side  of  the  operation,  some  on  the  other  side,  some  on  both 
sides.  They  were  the  unfavorable  cases — about  10  per  cent,  of  the  entire 
number. 

Fourteen  had  less  severe  recurrences,  coming  at  periods  of  from  a  few 
months  to  five  years,  on  the  side  of  the  original  operation. 

Four  had  secondary  operations  on  the  other  side — respectively  one,  one 
and  two-twelfths,  four,  and  five  and  a  half  years  after  the  primary  operation. 

Two  had  secondary  nodes  removed  only  from  the  axillae. 

The  number  of  cases  who  received  secondary  operations  is  16j^  per  cent, 
of  the  entire  number,  as  small  a  percentage  as  could  well  be  expected.  The 
results  were  excellent,  as  the  previous  tables  show. 

The  existence  of  hard  nodules  the  size  of  peas  or  beans,  or  even  larger, 
is  often  puzzling.  In  11  instances  I  have  excised  such  nodules,  sometimes 
after  watc^hing  them  two  or  three  years,  and  have  found  them  hyperplastic 
and  not  tubercular.     Apparently  they  enlarge  with  the  extra  function  which 


58  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

comes  to  them  after  the  removal  of  other  lymphatics.  We  can  indorse  Van 
Noorden's  statement  that  the  existence  of  these  small,  hard,  post-operative 
nodules  does  not  indicate  tuberculosis.  In  at  least  12  instances  I  have  seen 
them  diminish  in  size  or  disappear  during  a  period  of  long  observation. 


Tuberculosis  de  los  Nudos  Linfaticos  Cervicales.     Relate  de  275  Cases 
Tratados  por  medio  de  la  Extripacion  Radical. — (Dowd.) 

La  enfermedad  es  muy  grave;  la  mortalidad  de  los  casos  no  tratados 
es  un  poco  menos  de  50  por  ciento. 

Diferentes  tipos  de  la  infeccion. 

Formas  de  la  infeccion  segun  bovine  y  human.  Relate  de  veinte  casos 
estudiados  por  medio  de  la  inoculacion  y  las  culturas. 

Significacion  de  los  pequenos  nudos  endurecidos  que  aparecen  despues 
de  la  operacion.     Estudio  microscopico. 

La  operacion  por  lo  general  produce  menos  cicatrices  que  cuando  el 
caso  no  es  operado. 

La  mortalidad  de  los  casos  operados  es  una  tercera  parte  del  uno  por 
ciento.  La  cura  aparentemente  es  de  80  por  ciento.  Mejorfa  en  diez  6  mas 
por  ciento. 


Tuberculose  des   glandes  lymphatiques  cervicales.     Histoire  de  275  cas 
traites  par  extirpation  radicals. — (Down.) 

Maladie  grave:  mortalite  de  presque  cinquante  pour  cent  chez  les  per- 
sonnes  non  traitees. 

Divers  types  d'infection. 

Formes  bovine  et  humaine  d'infection.  Histoire  de  20  cas  etudies  par 
inoculation  et  culture. 

Signification  de  petits  ganglions  insensibles  posterieurs  a  I'operation. 

Etudes  microscopiques. 

Operation  rarement  suivie  de  cicatrice. 

Mortalite  dans  les  operations  bien  taites,  un  tiers  d'un  pour  cent. 
Guerisons,  a  peu  pres  80  pour  cent,  et  dix  ou  plus  pour  cent  d'ameliorations. 


Tuberkulose  der  cervicalen  Lymphdriisen.    Bericht  uber  175  Falle  von 
Radical-Exstirpation. — (Dowd.) 

Die  Erkrankung  ist  eine  ernste;  Mortalitat  unbehandelter  Falle  wahr- 
scheinUch  nicht  viel  unter  50  prozent. 
Verschiedene  Infektionstypen. 


TUBERCULOSIS   OF   THE   CERVICAL   LYMPH-NODES. — DOWD.  59 

Rincler-  und  menschiiche  Infektionsformen.  Bericht  iiber  20  Fiille 
sammt  Inoculations-  und  Culturen-Befunden. 

Die  Bedeutung  der  kleinen,  harten,  postoperativen  Knotchen.  Milo-o- 
skopische  Befunde. 

Operation  thut  gewohnlich  mit  der  sonstigen  Narbenbildung  hinweg. 

Mortalitat  nach  Radicaloperation  0.33  prozent.  Anscheinend  80  pro- 
zent  Ausheilungen,  mit  weiteren  10  prozent  oder  dariiber  von  Besseningen. 


DISCUSSION. 

Dr.  E.  M.  Sala  (Rock  Island,  111.)  said  he  had  had  very  good  results  in 
these  cases  with  the  x-ray  treatment.  There  was  no  question  in  his  mind 
but  what  the  x-ray  would  make  these  nodules  disappear  in  a  reasonable 
time.  His  custom  had  been  to  give  them  about  ten  minutes'  exposure  with 
a  good  strong  light,  at  a  distance  of  five  or  six  inches  from  the  tube.  He 
had  had  no  severe  burns  at  tliis  distance.  Surgery  was  the  proper  course  of 
procedure,  but  where,  for  any  reason,  that  could  not  be  resorted  to,  good 
results  could  also  be  had  from  the  use  of  the  x-ray. 

Dr.  Charles  H.  ]Mayo  (Rochester,  Minn.)  said  they  had  operated  on 
many  cases.  Children  under  eight  seldom  require  operation.  The  local 
focus  of  infection  should  be  eradicated,  if  possible;  that  is,  the  tonsil, 
adenoid  conditions  in  the  throat,  and  nasal  troubles.  If,  after  such  treat- 
ment, there  still  remains  for  a  period  without  improvement  enlargement 
of  the  glands  of  the  neck,  then  the  operation  would  be  indicated.  Later  in 
life  the  bulk  of  these  cases  should  be  treated,  not  only  by  the  removal  of 
the  local  focus,  if  that  can  be  done,  but  the  removal  of  the  glandular  group 
as  well.  Treatment  by  the  x-ray  does  leatherize  the  tissues,  producing  a 
gi-eat  deal  of  sclerotic  tissue,  and  in  that  way  is  favorable.  It  is  best  to 
recognize  onl}'  three  groups  of  cervical  glands — a  deep  group  on  each  side, 
and  a  submaxillary  and  submental  group — three  together.  If  tuberculosis 
attacks  one  gland,  the  whole  group  must  be  removed.  The  Ijanphatic 
system  is  very  closely  connected  with  the  blood,  and  it  is  no  farther  to 
the  lungs  through  the  lymphatic  than  through  the  air-passages.  Recurrence 
takes  place  because  the  entire  group  of  glands  had  not  been  removed. 

Dr.  Emil  G.  Beck  (Chicago),  spoke  of  the  use  of  bismuth  paste  in  the 
treatment  of  sinuses  in  connection  with  tuberculous  glands  of  the  neck. 
Only  three  cases  had  come  under  his  obser\'ation  which  could  be  treated  by 
this  method.  He  had  himself  treated  only  one  case,  and  in  that  case  he 
had  used  it  to  prevent  a  sinus.  This  patient  was  so  diseased  with  tuber- 
culosis anrl  had  so  many  sinuses  in  his  body  that  operation  was  not  advised, 
but  one  of  the  glands  was  suppurating  and  ready  to  open.  It  was  opened 
with  a  very  small  incision,  the  bismuth  paste  was  injected,  and  it  healed 


60  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

without  a  sinus.  Of  course,  it  might  have  healed  spontaneously.  Where 
any  tuberculous  tissue  had  been  left  within  the  tract  of  the  sinus,  or  where 
these  sinuses  had  become  infected  by  a  remaining  tuberculosis,  it  had  been 
proved  that  all  the  microorganisms  would  disappear  from  the  secretion  in 
three  or  four  days  following  the  injection  of  the  bismuth  paste. 

Dr.  Dowd,  in  closing,  said  he  had  found  one  class  of  cases  particularly 
in  which  the  x-ray  treatment  was  valual^le.  That  was  the  class  in  which 
the  infection  was  very  virulent.  The  tissue  resistance  is  very  low.  Such 
a  patient,  perhaps,  would  have  the  sternocleidomastoid  muscle  involved. 
The  glands  might  be  removed  as  thoroughly  as  possible,  but  a  few  weeks 
after  operation  there  would  be  a  diffuse  swelling  in  the  area  of  the  operation. 
These  cases  were  particularly  unfavorable  for  further  surgical  work.  Noth- 
ing would  remove  the  tuberculosis  short  of  the  most  radical  possible 
procedure,  taking  out  the  muscle  and  the  nerves  that  might  be  involved. 
That  might  be  done  for  cancer,  but  he  did  not  believe  it  wise  to  do  it 
in  tuberculosis.  These  cases  did  very  well  under  .r-ray  treatment.  There 
was  also  a  large  number  of  cases  which  would  do  well  under  .r-ray 
treatment  which  were  not  of  this  type.  But  a  good  many  cases  would 
also  do  well  under  any  form  of  treatment,  or  under  no  treatment  at 
all.  It  is  safe  to  say  that  at  least  half  the  cases  would  get  well  if  we 
did  not  do  an}'thing  for  them.  But  there  is  a  great  difference  between  this 
number  and  the  85  or  90  per  cent,  who  would  get  well  if  operated  on  as 
much  as  needed.  As  to  operations  on  children  under  eight  years  of  age,  he 
believes  that  depends  on  the  environment.  In  the  tenements  of  New  York, 
for  instance,  one  would  see  frightful  cases  under  eight  years,  and  he  was 
sure  many  of  these  cases  needed  operation.  However,  he  agreed  perfectly 
with  Dr.  ]\Iayo  that  there  are  many  others  who  would  get  well  without 
operation. 


RETROPERITONEAL  TUBERCULOUS  GLANDS  AND 
THEIR  RELATION  TO  SPINAL  SYMPTOMS. 

By  Charles  F.  Painter,  M.D., 

Professor  of  Orthopedic  Surgery  in  Tufts  Medical  School,  Boston,  Mass 


The  relation  of  extraspinal  abdominal  lesions  to  the  production  of  symp- 
toms referred  to  the  vertebral  column  is  a  matter  which  demands  more  atten- 
tion than  is  commonly  given  it.  The  close  approximation  of  the  abdominal 
viscera  to  the  anterior  surface  of  the  spinal  column  makes  it  possible  to 
incite  symptoms,  both  objective  and  subjective,  which  might  easily  lead  one 
astray,  not  only  as  to  the  location  of  the  lesions  in  question,  but  as  to  their 
actual  character.  Any  pathological  enlargement  of  the  organs  contained 
within  the  abdominal  cavity  may  readily,  through  mere  pressure  (e.  g., 
aneurism),  cause  a  list  of  the  trunk  and  more  or  less  restriction  in  the 
motions  of  the  spine.  This  is  especially  true  when  the  cause  for  such  path- 
ological enlargement  is  of  an  inflammatory  character,  resulting  in  the  deposit, 
in  the  tissues  about  the  anterior  surface  of  the  vertebral  column,  of  an  in- 
flammatory exudate.  Such  exudates  operate  in  two  ways:  they,  in  some 
cases,  extend  directly  to  the  osseous  structure  of  the  column,  and  erode  it, 
or  they  irritate  the  muscles  which  have  their  origin  or  insertion  upon  the 
column,  and  establish  a  condition  of  spasm  in  those  muscles  which  is  evi- 
denced by  pain,  impairment  of  function,  and  oftentimes  by  deformity. 

Perinephritic  and  nephritic  abscesses  and  aneurisms,  e.  g.,  are  capable  of 
doing  this  long  before  the  existence  of  lesions  of  the  kidney  or  blood-vessels 
is  even  suspected.  Inflammatory  conditions  about  the  colon  and  appendix 
give  rise  to  such  distinctively  characteristic  signs  that  it  is  only  rarely  that 
the  clinical  symptoms  are  spinal,  and  when  they  are  sufficiently  acute  to 
be  unmistakable,  the  patient  is  rarely  examined  to  see  if  there  are  signs 
suggesting  spinal  complication.  Acute  infectious  processes  in  bone,  e.  g., 
osteomyelitis,  and  even  subacute  infections,  may  cause  decidedly  signifi- 
cant spinal  symptoms. 

For  the  purposes  of  this  paper  it  will  not  be  necessary  to  go  exhaustively 
into  those  more  aggravated  types  of  mesenteric  and  retroperitoneal  gland- 
ular enlargements  which  are  known  as  "tabes  mesenterica,"  and  are  usually 
associated  with  emaciation,  tumefaction  of  the  abdomen,  peritonitis,  diar- 

61 


62  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

rhea,  and  vomiting.  Such  cases  commonly  occur  in  children,  and  in  a 
majority  of  instances  are  fatal. 

The  conditions  to  which  I  would  call  attention  are  more  frequently  noted 
in  adults,  and  declare  themselves  by  producing  symptoms  and  signs  indica- 
tive of  stiffness  and  deformity  of  the  vertebral  column.  In  some  cases 
symptoms  of  intestinal  obstruction  have  been  noted,  and  these  have  devel- 
oped, if  not  synchronously  with  the  spinal  symptoms,  at  any  rate  very  nearly 
at  the  same  time.  In  still  other  cases  large  abscesses  have  manifested 
themselves,  either  in  the  groins  or  perhaps  more  often  in  the  thigh,  leading 
one  to  suspect  the  existence  of  a  tuberculous  osseous  lesion  in  the  spinal 
column.  In  some  instances  one  may  find  the  suggestion  of  a  knuckle  and 
limitation  in  motion  of  the  vertebrae  in  such  localities,  but  more  often  the 
kyphos  is  lacldng. 

Warthin,*  discussing  tuberculous  lymphadenitis,  expresses  the  belief 
that  tuberculous  enlargement  of  the  retroperitoneal  and  mesenteric  glands 
is  more  common  than  is  generally  supposed.  He  bases  this  opinion  upon 
the  frequency  with  which,  at  autopsy,  lesions  of  this  kind  are  demonstrable. 
Many  of  these  glands  show  signs  of  having  passed  through  an  actively 
inflamed  stage,  followed  by  cicatrization  or  calcification.  He  tliinks  infec- 
tion of  other  parts  of  the  body  from  these  latent  foci  not  at  all  uncommon. 
He  is  of  the  belief  that  some  of  the  lesions  are  caused  by  the  bovine  form 
of  the  tubercle  bacillus,  and  others  still  by  the  human  type,  the  former 
being  the  common  source  of  infection  during  the  milk-drinking  period  of 
infancy  and  childhood.  Painter  and  Ervingf  obtained  statistics  which 
demonstrated  the  frequent  existence  of  these  lesions  at  autopsy.  Jacobi,t 
in  discussing  the  typical  "tabes  mesenterica,"  gives  expression  to  his  belief 
in  the  existence  of  a  less  aggravated  form  of  mesenteric  glandular  enlarge- 
ment than  that  described  as  "tabes." 

Anatomy. — A  brief  consideration  of  the  anatomy  of  this  region  may 
serve  to  make  more  clear  the  manner  in  which  enlargements  of  these  glands 
may  bring  about  irritative  changes  in  the  spine.  In  that  portion  of  the 
abdomen  where  the  radix  of  the  mesentery  is  attached  there  is  normally  a 
forward  bending  of  the  column,  constituting  the  normal  lordosis  of  the  spine, 
and  in  this  mesentery  run  the  lacteals  in  a  closely  intermingling  network  as 
they  pass  up'  to  become  the  large  chylous  duct  carrying  the  chyle  to  the 
venous  circulation. 

The  glands  in  this  region  are  numerous  and  serve  to  filter  out  bacilli 
which  may  be  carried  through  the  intestinal  mucous  membrane  by  the 
fatty  emulsion  to  which  the  food  is  reduced  prior  to  its  absorption.     Be- 

*  Osier's  "Modern  Medicine,"  vol.  iv,  p.  820. 

t  "Mesenteric  Tuberculosis,"  N.  Y.  Med.  Rec,  1903. 

X  Keating's  "Cyclopedia  of  the  Diseases  of  Children,"  1890,  vol.  iii. 


KETROPERITONEAL  TUBERCULOUS   GLANDS. — PAINTER.  63 

hind  the  mesentery  there  is  also  another  set  of  glands,  not  surrounded 
on  all  sides  by  peritoneum,  and  it  is  in  these  glands  particularly  that  those 
inflammations  occur  which  result  in  an  adherence  of  the  lymph-nodes  to 
the  anterior  surface  of  the  spinal  column. 

Pathology  and  Bacteriology. — Hemmeter  maintains  that  the  occur- 
rence of  calcification  and  caseation  in  the  retroperitoneal  and  mesenteric 
glands  is  sufficient  evidence  of  their  tuberculous  infection.  The  demon- 
stration of  tubercle  bacilli  in  the  tissues  or  by  animal  inoculation  is  not 
necessary.  He  cites  the  fact  that  autopsies  upon  phthisical  subjects  at  the 
age  of  eighteen  to  twenty  show  evidences  of  caseation,  whereas  such  autopsies 
at  forty  to  fifty  show  signs  of  calcification,  thus  indicating  that,  pathologi- 
cally, calcification  follows  caseation,  and  either  is  sufficient  evidence  of 
tuberculosis. 

Much  importance  attaches  in  scientific  discussions  in  these  times  to  the 
recognition  of  differences  between  the  bovine  and  human  forms  of  tubercle 
bacilli.  If  what  seems  to  be  true  eventually  can  be  proved,  it  will  be  of 
significance  in  the  matter  of  the  etiology  of  many  of  the  spinal  forms  of 
osseous  tuberculosis  that  seem  to  be  caused  by  direct  extension  from  the 
mesenteric  glands.  It  is  maintained  by  some  observers  that  the  glandular 
and  osseous  types  of  tuberculosis  are  caused  by  the  bovine  form  of  the 
tubercle  bacillus,  whereas  the  pulmonary  type  is  caused  by  the  human  form 
of  tliis  organism.  Glandular  and  osseous  tuberculosis  are  decidedly  more 
common  in  childhood,  and  pulmonary  tuberculosis  is  by  far  more  prevalent 
in  adults.  In  childhood  the  staple  of  diet  is  milk,  and  if  it  can  be  proved 
that  the  bovine  type  of  bacillus  is  invariably  found  in  the  tuberculous  lesions 
of  childhood  and  the  human  form  only  in  those  lesions  in  the  adult,  it  would 
seem  that  the  bovine  origin  of  glandular  and  osseous  tuberculosis  had  been 
pretty  well  established.  Kocli  still  contends  that  there  is  no  essential  differ- 
ence between  them.  Behring,  Theobald  Smith,  and  others  hold  the  opposite 
opinion.  There  have  been  a  good  many  experimental  demonstrations  of 
the  permeability  of  the  intestinal  coats  by  the  tubercle  bacillus.  Jones* 
has  shoMTi  that  virulent  forms  of  this  organism  may  remain  in  the  intestine 
for  long  periods  and  are  present  with  considerable  frequency.  Britterf 
has  demonstrated  twelve  out  of  twenty-five  varieties  of  bacteria  in  the  stools 
after  having  given  them  by  mouth,  thus  dispelling  the  theory  that  the  acids 
of  the  stomach  can  destroy  them  en  route.  RavenelJ  cites  literature  to 
prove  the  frequent  infection  of  the  glands  at  the  roots  of  the  bronchi  with 
tubercle  bacilli.  He  fed  cultures  of  this  organism  to  cats  through  a  catheter. 
In  from  six  to  ten  days,  in  75  per  cent,  of  the  cases  thus  infected,  these  animals 
had  peribronchial  tuberculosis.    These  experiments  and  those  of  others, 

♦"Physiology  of  Alimentation,"  Fisher,  1907. 

t  Deutsch.  med.  Woch.,  1885,  p.  843.  X  Jour.  Med.  Research,  vol.  x,  p.  460. 


64  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

notably  by  Droblanski,*  who  has  been  a  pioneer  in  this  Hne  of  investigation, 
have  demonstrated  the  infeetivity  of  the  glands  of  the  body  through  the 
alimentary  route.  Bramwellf  quotes  statistics  to  show  the  great  frequency 
of  glandular  tuberculosis  in  the  abdomen  in  Scotland,  as  compared  with  the 
United  States  and  Canada,  and  makes  the  suggestion  that  in  the  latter 
countries  better  milk  inspection  and  consequently  a  purer  supply  may  be 
responsible  for  this  condition.  At  the  children's  clinic  of  the  Mt.  Sinai 
Hospital  in  New  York,  for  the  seven  years  between  1898  and  1904,  there  were 
2266  patients  admitted  and  only  one  case  was  diagnosed  as  abdominal 
tuberculosis.  During  the  same  period  at  the  Edinburgh  Children's  Hos- 
pital there  were  10,213  admissions  and  378  cases  of  abdominal  tubercu- 
losis. 

Clinical  Course  and  Symptoms. — Having  cited  sufficient  data  to  make 
it  reasonably  clear  that,  anatomically  and  pathologically,  tuberculous  lesions 
may  occur,  and  as  a  matter  of  fact  do  occur,  in  the  mesenteric  and  retroperi- 
toneal glands,  and  that  these  structures  may  be  directly  infected  through 
the  intestinal  tract  without  demonstrable  lesions  having  been  produced  in 
the  tissues  of  the  intestine  as  the  bacilli  pass  through,  it  remains,  in  order 
to  fulfil  the  purposes  of  this  discussion,  to  call  attention  to  the  frequency 
with  which  lesions  so  produced  and  situated  may  give  rise  to  symptoms, 
and  more  especially  to  physical  signs,  which  are  strongly  suggestive  of  spinal 
disease — in  fact,  in  many  cases  are  the  forerunners  of  osseous  lesions  of  the 
spine. 

The  earliest  symptom  is  usually  pain  and  stiffness.  Great  difficulty  is 
experienced  in  assuming  an  erect  position  and  in  rising  from  a  low  chair  or 
a  bed  after  prolonged  confinement  to  either.  The  advent  of  these  symp- 
toms is  not  generally  rapid,  but  slow  and  gradually  augmented.  There  is 
frequently  a  slight  amount  of  deformity  noted  early,  as,  e.  g.,  a  list  to  one 
side  or  a  psoas  contracture,  causing  limp.  In  other  cases,  when  pain  is  not 
a  conspicuous  feature,  the  patient  complains  of  stiffness  in  the  spine  and 
may  note  a  swelling  in  the  thigh  or  lower  abdomen.  Indeed,  swelling  may 
be  the  earliest  suggestion  of  the  existence  of  something  wrong,  and  search 
for  the  origin  of  the  enlargement  brings  into  notice  the  existence  of  lesions 
more  or  less  remote.  As  a  rule,  the  swellings  which  occur  in  the  lower 
quadrants  of  the  abdomen  and  penetrate  occasionally  beneath  Poupart's 
ligament  are  not  inside  the  sheath  of  the  psoas  muscle,  and  therefore  do  not 
commonly  give  rise  to  the  symptom  of  contraction  and  consequent  flexion 
of  the  thigh. 

When  the  spine  is  examined,  the  lumbar  region  is  usually  found  to  be 
held  rigid  to  a  greater  or  lesser  extent.     Rarely  there  is  a  slight  anteropos- 

*  Arch,  de  Med.  Experiment,  d'anat.  Path.,  1890,  vi   250 
t  Chn.  Stud.,  Edinburgh,  1907-08,  vi,  1&-21. 


RETROPERITONEAL   TUBERCULOUS    GLANDS. — PAINTER.  65 

terior  curve,  which  may  be  dignified  by  the  name  of  a  k)'phos  in  some  cases, 
but  which  is  not  always  a  permanent  deformity,  though  it  may  have  a  strong 
resemblance  to  a  destructive  osseous  lesion.  A  significant  clinical  peculiarity 
of  these  pseudo-k}^3hoses  is  that,  though  two  or  three  spinous  processes 
may  take  part  in  the  development  of  the  deformity,  yet  in  view  of  the  rapid 
development  of  symptoms  it  is  not  sufficiently  angular  to  be  indicative  of  a 
central,  vertebral  lesion,  and  is,  therefore,  probably  due  to  spasm  of  the  spinal 
muscles.  Obliteration  of  the  lumbar  lordosis  is  practically  always  present. 
Rigidity  of  the  vertebrae  does  not  commonly  extend  above  the  eighth  or 
ninth  dorsal,  and  generally  not  quite  so  far.  Flexion  of  the  trunk  is  more 
readily  performed  than  lateral  motions  or  hyperextension.  Voluntary 
attempts  to  make  these  motions  are  not  usually  very  painful. 

Abdominal  palpation,  with  the  patient  as  much  relaxed  as  is  possible, 
preferably  immersed  in  a  hot  bath,  may  reveal  much  or  very  little.  At 
times  there  are  localized  accumulations  of  glands  in  the  region  of  the  root 
of  the  mesentery  or  about  the  colon  which  can  be  readily  palpated.  Their 
character  cannot  always  be  definitely  determined  by  palpation  alone.  More 
rarely  still  diffuse  masses  of  glands  may  be  felt  throughout  the  abdomen. 
Frequently  one  comes  upon  the  evidence  of  a  good-sized  cold  abscess,  gen- 
erally in  the  right  side  of  the  abdomen,  rather  more  toward  the  median  line 
than  it  is  customary  for  a  psoas  to  be  located.  When  these  abscesses 
gravitate  toward  the  groin,  they  follow  a  different  course  from  that  pursued 
bj^pus  within  the  psoas  sheath,  for  the  reason  that  the  latter  must  come  from 
the  vertebral  bodies  and  pursue  a  downward  and  outward  course.  These 
will  not  always  yield  a  sensation  of  fluctuation,  but  are  not  accompanied, 
as  a  rule,  by  spasm  of  the  rectus  muscle  on  that  side,  or  if  they  are,  it  is 
much  less  pronounced  than  in  more  acutely  inflammatory  conditions.  In 
some  of  the  diffuse,  nodular  accumulations  of  glands  there  is  more  rigidity 
of  the  recti  than  is  noted  in  the  suppurative  cases.  In  many  instances  the 
abscess  has  quietly  penetrated  beneath  the  psoas,  and  fluctuation  may  be 
obtained  through  from  thigh  to  lower  abdomen.  The  presence  of  the 
abscess  in  the  thigh  may  first  have  attracted  attention  by  an  increase  in  the 
circumference  of  the  thigh. 

Constitutional  symptoms  should  be  carefully  studied  in  these  patients. 
The  presence  of  a  continued  slight  evening  rise  of  temperature  is  very 
suggestive  of  a  tuberculous  condition,  and  with  such  symptoms  referable  to 
the  abdomen  and  no  anteroposterior  deformity  of  the  spine,  the  evidence 
in  favor  of  a  tuberculous  adenitis  becomes  much  stronger.  Occasionally, 
by  palpation,  bimanually,  in  the  loin,  deep-seated  suppuration  may  be 
detected  both  through  the  sensation  of  fluctuation  and  by  the  presence  of  a 
tender  mass.  A  septic  temperature  is  rarely  met  with  in  this  condition. 
Occasionally  vertebral  osteomyelitis  may  present  symptoms  not  greatly 

VOL.  II — 3 


66  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

unlike  these.  A  secondary  anemia  is  not  uncommon.  An  a;-ray  examina- 
tion ought  always  to  be  made.  It  will  sometimes  be  possible  in  this  way 
to  demonstrate  the  existence  of  glands,  particularly  if  they  have  become 
calcareous.  In  some  instances  it  is  possible  to  develop  the  negative  so  that 
accumulations  of  glands  which  have  not  as  yet  calcified  may  be  demon- 
strated. Even  when  such  positive  evidence  is  wanting,  the  ability  to  ex- 
clude the  possibility  of  an  osseous  vertebral  lesion  is  helpful  in  reaching  posi- 
tive conclusions  regarding  the  glands.  When  a  clear  bill  of  health  can  be 
given  the  spine  in  the  x-ray  examination,  some  of  the  diagnostic  difficulties 
are  removed. 

Complications  and  Sequels. — The  common  complications  caused  by 
the  presence  of  these  enlarged  glands  in  the  retroperitoneal  region  and  in 
the  mesentery  are  abscess,  extension  to  the  vertebrae,  and  intestinal  ob- 
struction. Suppuration  is  very  common,  is,  in  fact,  perhaps  the  rule.  It 
may  be  confined  to  one  small  group  of  glands  which  become  matted  together 
and  then  break  down,  or  sinuses  may  appear  in  several  places  in  the  same 
person  at  the  same  time.  The  most  common  seat  of  suppuration  is  the  groin 
and  thigh.  Occasionally  an  abscess  will  appear  in  the  lumbar  region.  Pus 
obtained  from  these  will  frequently  give  positive  evidence  of  the  tuberculous 
nature  of  the  trouble  upon  smears  or  injection  into  animals. 

Extension  of  tuberculous  disease  from  the  affected  glands  to  the  vertebral 
column  cannot  often  be  positively  demonstrated,  but  one  case,  to  which 
attention  is  called  among  the  cases  cited,  seems  to  the  writer  conclusive 
proof  that  such  may  be  the  sequence.  In  this  case  there  had  been  more 
than  a  year  of  observation  of  the  patient,  during  which  time  the  low  dorsal 
and  lumbar  spine  became  stiff  and  was  held  so  by  muscle  spasm.  At  the 
end  of  that  period,  during  which  time  he  had  worn  a  leather  jacket,  a  large 
abscess  appeared  in  the  thigh  and  groin.  This  was  aspirated.  Ten  days 
later  the  patient  manifested  signs  of  intestinal  obstruction  and  died.  An  au- 
topsy showed  extensive  glandular  tuberculosis,  which  had  matted  the  intes- 
tines together,  and  opposite  the  point  of  their  greatest  adhesion  they  had  also 
become  attached  to  the  lumbar  vertebrae,  where  there  was  a  marked  erosion 
of  these  bones  and  caseating  tubercles  were  present.  Apparently,  the  older 
process  was  in  the  glands,  which  had  become  calcified  in  many  places.  This 
is  the  only  instance  in  my  personal  experience  where  it  has  been  possible  to 
demonstrate,  l)y  post-mortem  examination,  the  direct  extension  of  tuber- 
culous glandular  disease  to  the  vertebral  column,  thus  causing  a  true  Pott's 
disease. 

In  two  other  patients,  however,  glands  have  been  demonstrated  in  great 
abundance  in  the  mesentery  and  retroperitoneal  regions,  and  in  both  these 
cases  indications  of  spinal  disease  were  the  most  striking  symptoms  which 
the  patients  presented,  and  in  both  cases  the  spinal  symptoms  improved 


RETROPERrrONEAL   TUBERCULOUS   GLANDS. — PAINTER.  67 

coincidentally  with  the  betterment  of  the  glandular  disease.  One  of  these 
cases  was  operated  upon  to  see  if  it  was  possible  to  remove  the  glands.  They 
were  retroperitoneal  and  filled  the  entire  abdomen,  practically  displacing 
the  intestine.  Nothing  could  be  accomplished  surgically.  Subsequently 
four  sinuses  developed,  two  in  the  groins  and  two  in  the  loins.  After  pro- 
tracted suppuration  the  glands  all  disappeared,  the  sinuses  closed,  the  spine 
became  freely  movable,  the  patient  gained  80  pounds  in  weight,  and  is 
perfectly  well,  doing  hard  work  as  a  laborer. 

The  other  case  which  came  to  operation  had  an  emergency  laparotomy 
for  intestinal  obstruction.  He  had  been  under  treatment  for  spinal  symp- 
toms, though  the  glandular  condition  in  the  abdomen  had  been  suspected, 
and  he  had  been  seen  in  consultation  by  a  surgeon  with  a  view  to  exploration 
over  a  month  before  his  intestinal  symptoms  appeared.  These  glands  were 
small,  and  were  in  the  mesentery  mostly,  but  caused  matting  of  the  intes- 
tines and  obstruction.  After  the  operation  there  was  quite  marked  im- 
provement, both  in  the  general  condition  and  in  the  local  signs  in  the  spine, 
though  nothing  like  as  pronounced  as  occurred  in  the  patient  whose  glands 
were  retroperitoneal. 

One  instance  further  adds  its  testimony  to  this  series  of  cases.  The 
patient  was  a  young  man  who  had  pain,  stiffness,  and  a  list  of  the  spinal 
column.  Later  there  appeared  rigidity  of  the  right  rectus  muscle  and  a 
mass  in  the  abdomen.  This  mass  increased  in  size,  and  about  a  year  after 
the  first  symptoms  were  noted,  was  operated  upon  and  a  large  amount  of 
pus  was  obtained,  some  of  which,  when  inoculated  into  a  guinea-pig,  pro- 
duced in  due  time  typical  tuberculous  visceral  lesions.  The  operative  wound 
remained  open  for  from  four  to  six  weeks.  As  the  list  of  the  spine  did  not 
readily  correct  itself,  an  x-ray  examination  was  made,  and  a  small  osseous 
focus  could  be  demonstrated  on  the  anterolateral  aspect  of  the  body  of  one 
vertebra — the  eleventh  dorsal.  Two  years  after  the  incidence  of  symptoms 
in  this  case  there  was  a  slight  suggestion  of  a  kyphos  in  this  region  and  a 
very  slight  lateral  deviation  of  two  or  three  spinous  processes.  The  patient 
has  been  entirely  well  some  six  or  eight  years.  In  this  case  positive  proof 
of  the  existence  of  glands  is  wanting,  but  the  sequence  of  clinical  events 
makes  it  more  than  likely,  it  seems  to  me,  that  this  was  a  case  of  primary 
glandular  disease  which  extended  directly  to  the  spine. 

It  is  not  necessary  here  to  more  than  allude  to  the  third  serious  complica- 
tion which  these  glands  may  give  rise  to,  as  it  belongs  more  in  the  province 
of  the  general  surgeon.  I  mention  it  only  because  it  so  happens  that  intes- 
tinal obstruction  has  occurred  in  two  of  my  cases  where  spinal  symptoms 
were  the  conspicuous  ones  from  the  outset,  and  one  should  be  on  the  watch 
for  this  condition  in  patients  with  these  signs. 

Differential  Diagnosis. — Enlarged  tuberculous  glands  must  be  differ- 


68  SIXTH   INTERNATIONAL   CONGRESS    ON   TUBERCULOSIS. 

entiated  from  aneurisms,  gummata,  actinomycosis,  sarcoma,  and  carci- 
noma, the  infectious  and  h3qjertrophic  types  of  arthritis,  perinephritic  and 
nephritic  abscesses,  appendicitis,  and  osteomyehtis.  From  aneurism  the 
age  of  the  patient,  as  well  as  the  physical  signs  of  arterial  degeneration  and 
the  specific  indications  of  an  aneurism,  must  be  searched  for.  A  history 
of  syphilis  would  make  it  necessary  to  try  the  therapeutic  test  in  order  to 
eliminate  the  possibility  of  such  an  infection.  Actinomycosis  is  rarely  a 
cause  for  intra-abdominal  glandular  enlargement.  Examinations  of  the  pus 
or  the  existence  of  other  actinomycotic  lesions  might  clear  up  the  diagnosis. 
Malignant  disease  of  the  abdomen  would  be  rare  in  individuals  at  the  age 
of  patients  who  most  frequently  suffer  from  mesenteric  glandular  enlarge- 
ments. Primary  sarcoma  of  the  spine  is  more  common  in  young  people  than 
is  carcinoma.  Primary  carcinoma  of  the  spine  is  practically  unknown. 
Vertebral  osteomyelitis  has  all  the  clinical  characteristics  of  acute  osteomyeli- 
tis elsewhere,  and  should  be  capable  of  differentiation  without  difficulty. 
Infectious  and  hypertrophic  arthritis  usually  more  completely  stiffen  the 
column,  and  the  latter,  at  least,  is  characterized  by  a  certain  amount  of 
motion  in  some  directions.  There  are  commonly  other  parts  of  the  body 
affected  in  a  similar  manner  in  these  conditions. 

Treatment. — The  management  of  these  cases  is  largely  dependent  upon 
good  hygiene,  wholesome  diet,  and  surgical  rest.  Inunctions  and  various 
internal  medications  have  been  tried  without  avail.  Operative  measures, 
except  when  directed  to  the  aspiration  of  abscesses,  is  rarely  indicated.  A 
few  successful  cases  of  removal  of  these  glands  have  been  reported.  Fixation 
of  the  spine  is  helpful  in  controlling  pain,  and  possibly  in  preventing  exten- 
sion from  the  glands  to  the  vertebral  column. 

Prognosis. — My  experience  with  the  foregoing  cases  and  with  some 
others  not  here  reported  leads  to  the  belief  that  no  case  of  this  condition  is 
so  desperate  that  it  may  not  recover.  Certainly  some  of  the  most  distressing 
conditions  have  been  restored  to  health  when  there  was  apparently  absolutely 
no  reason  to  expect  they  would  be.  The  serious  complications  are  those 
which  tie  up  the  intestines  so  that  intestinal  obstruction  is  brought  on.  My 
belief  is  that  the  mesenteric  glandular  enlargements  are  much  more  serious 
than  the  retroperitoneal. 

Conclusions. — It  has  been  pretty  conclusively  proved  that  the  intestinal 
route  is  frequently  employed  by  the  tubercle  bacillus  in  gaining  access 
to  the  human  body.  This  organism  may  pass  the  stomach  unchecked  in  its 
progress,  and  make  its  way  through  the  intestinal  coats  without  producing 
any  evidence  in  these  structures  of  its  passage.  It  has  been  shown  that  the 
mesenteric  retroperitoneal  as  well  as  the  bronchial  lymphatic"  glands  may 
become  infected  in  this  manner.  Clinical  evidence  of  the  enlargement  of 
these  glands  may  often  be   obtained.     It   has   been   demonstrated  that 


RETROPERITONEAL   TUBERCULOUS   GLANDS. — PAINTER.  69 

they  at  times  may  lie  so  close  to  the  front  of  the  vertebral  column  that 
they  may  erode  the  bone,  and  that  in  those  cases  symptoms  were  present 
pointing  conclusively  to  the  spine  as  the  seat  of  a  lesion.  It  is  seemingly 
not  necessary  that  the  glands  should  actually  erode  the  column  in  order  to 
give  rise  to  symptoms,  because  cases  are  on  record  where  the  glands  were  in 
evidence  and  spinal  symptoms  were  present,  though  no  sign  of  vertebral 
erosion  could  be  obtained.  In  the  course  of  the  recovery  of  the  case  clinical 
evidences  of  the  existence  of  glands  disappeared,  and  synchronously  with 
that  spinal  symptoms  could  not  longer  be  detected.  Treatment  is  largely 
constitutional.     Prognosis  is  in  the  main  good. 

The  following  cases  are  more  or  less  typical  of  the  condition  in  question. 

Case  I. — Mr.  T.,  thirty  years.  Diagnosis,  tuberculosis  of  abdominal 
lymph-nodes  and  tuberculosis  of  the  astragalus.     Recovery. 

Up  to  two  months  before  seeking  treatment  the  patient  had  been  per- 
fectly well.  First  complained  of  pain  in  back  and  abdomen.  Motions  in- 
volving the  spine  were  painful,  and  the  patient  soon  became  conscious  of 
limitation  in  motions  of  the  back.  When  examined,  there  was  rigidity  of  the 
spinal  muscles  and  obliteration  of  the  lumbar  curve,  no  anteroposterior 
deformity.  Abdominal  muscles  were  quite  rigid,  but  at  first  there  were  no 
glands  detectable  and  no  mass  could  be  felt  in  the  abdomen.  Later  on  a 
definite  abscess  could  be  palpated  in  the  right  groin.  This  was  opened  out- 
side the  peritoneum  and  drained  for  some  months.  Inoculation  tests  proved 
this  to  be  tuberculous.  Shortly  after  this  extensive  osseous  disease  developed 
in  the  astragalus,  and  this  bone  was  excised.  Spinal  symptoms  continued 
for  over  two  years,  during  which  time  a  jacket  was  worn.  No  kyphos 
developed. 

Case  II. — Miss  J.  B.,  twenty-six  years.  Diagnosis,  tuberculosis  of  the 
lungs,  knees,  and  retroperitoneal  glands.     Pott's  disease. 

When  a  young  girl,  the  patient  had  signs  pointing  to  pulmonary  tuber- 
culosis. These  subsided,  and  for  several  years  she  has  had  no  trouble  in 
this  region.  Nine  years  ago  had  an  excision  of  the  right  knee.  Eight  years 
later  acute  signs  developed  in  the  left  knee,  and  an  exploratory  incision  was 
made  into  this  joint,  and  erasion  of  extensive  tuberculous  disease  was  prac- 
tised. Six  months  ago  the  patient  first  complained  of  pain  and  stiffness  in 
the  lower  spine.  There  was  no  deformity  present,  but  considerable  spasm 
of  muscles  and  gradually  a  slight  prominence  of  two  or  three  low  dorsal  and 
lumbar  vertebrae  was  noticed.  A  swelling  subsequently  became  apparent 
in  the  right  thigh,  and  at  the  same  time  there  was  considerable  pain  referred 
to  the  front  of  the  thigh.  A  mass  could  be  felt  in  the  right  groin.  This 
proved  to  be  an  abscess,  and  communicated  with  the  abscess  in  the  abdomen. 
It  was  aspirated  through  the  thigh,  and  three  quarts  of  tuberculous  appearing 
pus  was  drained.  Palpation  of  the  abdomen  elicits  considerable  rigidity  of 
the  abdominal  muscles,  but  no  glands  can  be  positively  felt.  The  kyphos 
has  practically  disappeared,  and  with  a  leather  jacket  the  patient  gets  about 
very  well. 

Case  III. — Mr.  L.,  thirty-five  years.  This  patient  was  treated  at  first 
for  a  non-tuberculous  disease  of  the  spine,  seemingly  of  the  hjToertropliic 


70  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

type.  He  wore  a  jacket  for  some  months,  and  returned  to  his  home  in 
Canada.  After  remaining  there  one  year  he  returned  in  poor  condition  and 
had  a  very  large  abscess  which  fluctuated  both  above  and  below  Poupart's 
ligament.  This  was  aspirated,  and  a  large  amount  of  tuberculous  pus  was 
evacuated.  Ten  days  later  he  developed  very  acute  intestinal  symptoms 
and  was  operated  for  intestinal  obstruction.  The  patient  died,  and  at  the 
autopsy  there  were  found  many  enlarged  lymph-glands  matting  the  intestinal 
coils  together  and  holding  the  gut  close  against  the  lumbar  spine,  in  conse- 
quence of  which  the  disease  in  the  glands  had  extended  to  the  lumbar  verte- 
brae and  eroded  two  of  them.  The  glands  were  calcified  in  some  instances, 
and  seemed  to  represent  the  oldest  lesion. 

Case  IV.— Mr.  M.,  twenty  years.  This  patient  was  a  healthy  young 
man  employed  in  the  navy  yard.  He  first  complained  of  pain  in  the  lower 
back  and  lameness.  This  was  in  the  winter  of  1897.  He  became  considerably 
bent  over,  and  was  obliged  to  give  up  work.  When  examined  at  that  time 
there  was  flexion  of  the  trunk,  rigidity  of  the  lower  spine,  no  kyjjhos,  spasm 
of  the  abdominal  muscles,  and  on  palpation  of  the  abdomen  there  was 
distinct  fullness  and  resistance  in  both  groins.  This  fullness  was  caused  by 
glandular  masses  which  were  nodular  in  feel.  The  patient  emaciated 
rapidly,  and  was  much  troubled  by  constipation.  Exploratory  incision  was 
advised,  and  performed  by  Dr.  Wm.  Conant.  The  intestines  were  pushed 
up  into  the  upper  abdomen,  and  the  entire  region  below  them  was  occupied 
by  a  mass  of  glands,  most  of  which  were  discrete,  but  many  were  matted 
together  and  had  commenced  to  caseate.  Subsequently  these  broke  down 
in  four  places,  and  sinuses  developed  in  both  loins  and  both  groins.  These 
discharged  pus  freely  for  many  months,  and  did  not  wholly  close  for  two 
years.  Four  years  later  the  patient  was  seen  and  there  was  no  sign  of  any 
limitation  of  spinal  motion.  The  abdomen  was  soft,  the  sinuses  were  closed, 
and  the  patient  seemed  in  perfect  health.  When  he  was  at  his  worst  his 
weight  had  fallen  to  below  100  pounds,  but  when  last  examined  he  was 
weighing  180  pounds. 

Case.  V. — ^Ir.  Z.,  thirty-one  years.  In  the  winter  of  1906  this  patient 
came  to  the  clinic  complaining  of  pain  in  the  lower  back  and  hips.  This 
had  been  of  gradual  development.  He  carried  himself  stiffly,  but  stood 
erect.  His  spinal  motions  were  all  guarded,  and  the  normal  curves  of  the 
spine  were  obliterated.  Spinal  motions  painful.  Patient  seemed  sick  and 
was  carrying  a  degi'ee  and  a  half  of  fever.  A  plaster  jacket  was  applied, 
which  relieved  his  pain  very  promptly.  He  seemed  much  better  during  the 
next  month,  but  as  the  spinal  stiffness  did  not  change,  a  new  jacket  was 
applied,  and  while  wearing  this  he  was  suddenly  seized  by  acute  abdominal 
pain,  which  had  been  preceded  by  more  or  less  pain  and  constipation.  When 
the  jacket  was  removed,  the  abdomen  was  found  to  be  quite  rigid  and 
tender,  but  nothing  else  could  be  made  out.  Patient  was  admitted  to  the 
surgical  service,  and  when  the  abdomen  was  opened,  it  was  found  that  the 
coils  of  intestine  were  glued  together,  and  the  mesentery  was  full  of  small 
glands.  The  spine  seemed  entirely  normal,  so  far  as  it  could  be  palpated 
from  the  abdominal  side.  His  convalescence  was  uninterrupted.  The 
spinal  rigidity  lessened,  though  it  did  not  wholly  disappear,  and  there  were 
no  further  symptoms  while  he  was  under  observation. 

Case  VI. — Mr.  P.  B.,  twenty-five  years.    This  patient  was  a  strong, 


RETROPERITONEAL   TUBERCULOUS   GLANDS. — PAINTER.  71 

healthy  student  who  commenced  to  complain  of  pain  in  the  lower  back  and 
right  side  in  the  spring  of  1901.  Shortly  after  this  the  trunk  commenced 
to  list  to  the  left,  and  a  mass  appeared  in  the  right  side  of  the  abdomen,  a 
little  to  the  right  of  the  median  line.  As  this  increased  in  size  it  was  aspi- 
rated. Pus  from  this  was  inoculated  in  a  guinea-pig  and  produced  typical 
tuberculous  lesions.  Under  the  use  of  jackets  and  braces  the  list  of  the  body 
was  gi'adually  righted.  The  sinus  closed  in  a  few  weeks,  and  the  patient's 
pain  gradually  disappeared.  Two  years  after  the  commencement  of  the 
trouble  there  was  a  slight  prominence  of  one  or  two  spinous  processes,  and 
an  a:-ray  showed  a  sharply  localized  erosion  on  the  side  of  the  body  of  one 
vertebra. 

Case  VII. — i\Ir.  L.,  twenty-seven  years.  This  young  man  came  to  the 
hospital  complaining  of  sharply  localized  pain  in  the  lower  back  on  the  left 
side.  This  has  been  troubling  him  about  tht*ee  weeks.  Previous  to  the 
commencement  of  this  he  had  regarded  himself  as  entirely  well.  When  he 
was  first  examined,  there  was  no  spinal  limitation  and  only  a  tender  area 
the  size  of  a  twenty-five-cent  piece  just  to  the  median  side  of  the  left  posterior 
or  superior  spine.  In  the  course  of  a  couple  of  weeks  a  swelling  appeared 
here.  He  was  then  admitted  to  the  hospital  and  operated.  Tliis  swelling 
represented  an  abscess  which  came  up  from  the  pelvis.  It  appeared  to  be 
tuberculous.  The  wound  became  an  extensive  ulceration,  which  only  slowly 
closed  in.  His  spine  became  stiff  in  the  lumbar  region.  The  muscles  of 
the  abdomen  were  rigid,  and  on  the  right  side  there  seemed  to  be  a  palpable 
mass  which  was  tender  to  pressure.  He  was  treated  in  the  hospital  for  a 
long  time  with  mixed  toxins  of  tuberculosis  and  the  streptococcus,  but  soon 
developed  signs  of  phthisis  and  later  of  miliary  tuberculosis  and  died.  No 
autopsy  was  permitted.  No  kyphos  developed  at  any  time,  and  there  was 
nothing  to  suggest  osseous  disease. 

Case  VHI. — Mr.  C,  nineteen  years.  This  patient  came  to  the  hospital 
complaining  of  pain  in  the  left  lower  back,  and  a  limp  due  to  left  psoas  con- 
tracture. On  examination  the  lumbar  spine  was  rigid  and  the  trunk  was 
listed  to  the  left.  There  was  a  mass  to  be  felt  in  the  left  side  of  the  abdomen. 
The  left  leg  could  not  be  completely  extended,  but  except  for  this  there  was 
no  limitation  in  the  motions  at  the  hip- joint.  The  patient  was  put  to  bed 
and  traction  applied  to  the  hip  in  order  to  overcome  the  flexion.  There 
was  no  kyphos  in  the  spine.  The  abscess  in  the  abdomen  was  ckained 
through  the  groin,  and  later  two  or  three  fistulas  appeared  spontaneously 
in  the  left  and  one  in  the  right  loin.  For  about  a  year  the  general  concUtion 
was  bad,  and  the  patient's  recovery  seemed  doubtful.  Within  three  years 
of  the  time  the  trouble  commenced  he  had  improved  to  such  an  extent  that 
the*  sinuses  had  all  healed,  the  spinal  motions  had  been  restored  to  normal, 
and  there  was  no  longer  any  abdominal  rigidity.  At  no  time  was  there  a 
kyphosis  in  this  case. 

As  will  be  noted  in  reading  the  accounts  of  these  cases,  there  is  no  abso- 
lute proof  in  any  but  one  or  two  of  the  patients  that  the  spinal  symptoms 
were  caused  by  the  presence  of  glands  of  a  tuberculous  nature,  so  situated 
that  they  pressed  upon  and  eroded  the  vertebral  bodies,  yet  the  symptoms 
in  these  cases,  when  the  positive  proof  of  spinal  erosion  is  lacking,  are  so 


72  SIXTH   INTERNATIONAL  CONGRESS   ON   TUBERCULOSIS. 

similar  to  those  noted  in  the  case  where  demonstration  of  this  osseous  lesion 
was  possible  that  it  seems  reasonable  to  conclude  that  they  all  belong  to 
the  same  class. 

DISCUSSION. 

Dr.  Wisner  R.  Townsend  (New  York)  said  he  appreciated  the  impor- 
tance of  these  conditions  which  simulated  spinal  disease,  and  he  thought  the 
Boston  school  of  orthopedics  deserved  a  great  deal  of  credit  for  bringing 
forward  more  information  on  these  subjects.  It  seemed  to  him  that  the 
most  important  thing  they  had  done  in  the  last  few  years  in  regard  to  spinal 
lesions  was  in  having  made  it  possible  more  clearly  to  differentiate  the  symp- 
toms. It  was  unfortunate,  in  this  class  of  cases,  that  an  early  diagnosis 
often  could  not  be  made.  But  it  was  a  very  good  thing  to  call  attention  to 
the  fact  that  these  conditions  did  exist,  and  that  they  were  not  so  uncommon 
as  had  generally  been  supposed.  A  great  many  escaped  observation  entirely, 
being  treated  as  lumbago,  etc.,  whereas  in  reality  they  were  the  beginning 
symptoms  of  a  more  serious  condition. 

Dr.  Charles  H.  Dowd  (New  York)  asked  what  experience  they  had  had 
in  the  removal  of  the  mesenteric  glands  in  these  mild  cases.  He  had  had 
the  experience,  in  the  well-marked  cases  of  tabes  mesenterica,  and  had  been 
very  much  surprised  to  find  how  easy  it  was  to  remove  large  masses  of  these 
nodes  and  to  get  a  good  healing.  He  had  not  had  any  experience,  however, 
in  operating  on  the  class  of  cases  referred  to  in  the  paper.  Surgery  surely 
offered  a  very  promising  field  of  treatment  for  this  condition,  and  he  wished 
to  know  whether  the  writer  of  the  paper  had  operated  upon  any  of  the  cases. 

Dr.  Painter,  in  closing,  said  that  a  good  deal  of  work  had  been  done  on 
the  aggravated  form  of  these  mesenteric  enlargements,  but  he  had  not 
operated  on  any  of  the  cases  of  the  milder  type.  He  had  been  unable  to 
persuade  surgeons  as  to  the  advisability  of  making  laparotomies  in  these 
cases.  On  the  other  hand,  he  had  seen  some  very  serious  cases,  which  the 
surgeons  had  considered  hopeless,  and  in  which  spontaneous  recovery  took 
place.  Therefore,  the  determination  of  what  cases  should  be  subjected  to 
surgical  treatment  was  still  an  open  question. 


SURGICAL  ASPECTS  OF  TUBERCULOSIS  OF  THE 
LUNG  AND  PLEURA. 

By  Samuel  Robinson,  M.D., 

Boston. 


Surgery  may  well  boast  of  increasing  successes  in  certain  regions  of  the 
body,  but  within  the  chest  cavity  progress  has  indeed  been  limited. 
Furthermore,  for  the  results  of  operative  treatment  of  tuberculosis  of  the 
lung  and  pleura,  surgery  may  claim  even  less  credit. 

Ten  years  ago  J.  B.  Murphy,  of  Chicago,  in  a  surgical  oration  reviewed 
the  status  of  lung  surgery  at  that  time.  Abscess  of  the  lung,  actinomycosis, 
bronchiectasis,  gunshot  wounds,  and  foreign  bodies,  thanks  to  a  goodly 
number  of  collected  results,  he  regarded  as  conditions  warranting  surgical 
treatment.  During  the  past  ten  years  the  number  of  such  operations  has 
increased  with  proportionately  somewhat  better  results,  thanks  to  the  work 
of  Carre,  Karewski,  Korte,  Tilton,  and  others. 

But  despite  the  hopeful  results  of  such  intrathoracic  operations,  we  must 
on  this  occasion  adhere  to  the  treatment  of  tuberculous  lesions,  and  in  1898 
Murphy  was  evidently  of  the  opinion  that,  up  to  that  time,  surgery  had  been 
of  comparatively  little  benefit  in  the  treatment  of  pulmonarj^  tuberculosis. 
Cases  of  drained  tuberculous  cavities  were  then,  as  now,  in  the  literature, 
but  iMurphy  was  doubtless  correct  in  stating  that  this  procedure  was  attended 
with  uncertainty.  The  opening  of  one  cavity  often  meant  that  one  or  more 
neighboring  ones  were  left  unoperated.  The  results  in  certain  cases,  how- 
ever, were  relief  to  the  patient  in  diminished  expectoration  and  cough.  Nor 
did  ^lurphy  abandon  the  advisability  of  operating  in  certain  favorable  cases 
where  such  improvement  was  promising.  A  review  of  the  results  of  partial 
excision  of  pulmonary  tuberculous  foci,  partial  pneumectomy,  was  then 
most  discouraging.  Murphy,  in  the  same  oration,  advocated  the  injection  of 
nitrogen  into  the  pleural  cavity  to  partially  collapse,  and  thus  immobilize, 
the  diseased  lung. 

Ten  years  have  elapsed  since  this  review;  what  more  can  be  claimed  to- 
day in  behalf  of  the  surgery  of  tuberculous  intrathoracic  lesions? 

The  drainage  of  tuberculous  cavities  is  still  undertaken,  but,  it  must  be 
admitted,  with  the  same  uncertainty  as  to  relief — with  much  the  same 
dangers  as  to  convalescence — and  with  quite  as  Uttle  hope  of  cure.  For  the 
relief  of  symptoms  in  certain  cases  its  value  cannot  be  denied. 

73 


74  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

As  to  the  results  of  excisions,  the  hterature  of  the  past  ten  years  con- 
tributes Httle  encouragement.  The  cases  of  Tuffier,  Lowson,  and  Doyen 
still  stand  practically  alone  as  successful  excisions  of  tuberculous  lung-lobes. 
As  a  result  of  considerable  animal  experimentation,  I  have  come  to  regard 
the  removal  of  one  or  two  lobes  of  the  lung  of  a  dog  or  rabbit  as  an 
operation  attended  with  absolute  surety  of  success.  Mayer,  Green,  and 
Janeway  would,  I  think,  support  me  in  tliis  conviction,  and  although  our 
experimental  successes  in  the  last  few  years  tend  to  undue  hopefulness  for 
lung  excisions  in  the  future,  it  is  difficult  to  abandon  the  possibilities  of  such 
operations  on  tubercular  foci  as  willingly  as  we  abandoned  them  ten  years 
ago.  It  must  be  conceded,  however,  that  pneumectomy  in  the  human  lung 
in  the  presence  of  adhesions  is  quite  a  different  problem  from  the  same 
operation  in  the  normal  animal.  Professors  Brauer  and  Sauerbruch,  of 
Marburg,  men  of  considerable  clinical  and  experimental  experience,  have 
recently  courteously  answered  my  personal  inquiries  on  this  subject;  they 
are  of  the  opinion  that  the  excision  method  of  approaching  pulmonary 
tuberculosis  offers  little  encouragement  for  the  future. 

Clinical  progress  has,  however,  been  marked  in  one  direction  at  least. 
Like  other  tubercular  lesions,  where  excision  is  not  possible,  rest  of  the 
diseased  part  leads  to  relief  and  often  to  cure.  I  refer  to  the  different 
methods  of  collapsing  the  lung,  and  thus,  as  it  were,  splinting  it.  The  plastic 
operations  of  Estlander  and  Schede  have  long  been  utilized  for  obliterating 
the  chest  cavity  in  cases  of  chronic  empyema.  Garre,  Quincke,  Friedreich, 
Kuttner,  and  others  are  now  utilizing  similar  plastic  operations  to  collapse 
and  immobilize  the  tuberculous  lung.  In  the  previously  ascertained  absence 
of  adhesions,  prolonged  but  not  permanent  collapse  of  the  lung  is  produced 
by  the  injection  of  nitrogen  into  the  pleural  cavity,  as  suggested  by  Fallonini 
and  Murphy.  By  repeated  injections  of  this  slowly  absorbed  gas  a  partial 
splinting  is  maintained,  in  which  time,  as  Rudolph  Brauer  emphasizes,  the 
absorption  of  toxins  is  diminished  by  the  lessened  lymph  circulation;  the 
tubercle  bacilli  thrive  less  successfully  and  decrease  in  the  sputum;  expec- 
toration is  diminished,  and  the  night-sweats  cease. 

In  early  apical  tuberculosis  cures  have  been  claimed  after  Freund's  oper- 
ation, developed  by  Seidel,  in  which  by  mobilizing  the  first  rib,  the  excursion 
of  the  upper  thorax  is  increased  and  the  apices  are  rendered  less  prone  to 
inactivity  and  bacterial  invasion. 

Furthermore,  most  surgical  clinics  record  successful  results  in  drainage 
and  plastic  operations  for  the  relief  and  cure  of  tuberculous  empyema,  and 
if  we  accept  the  statement  that  85  per  cent,  of  all  adult  empyemas  are  of 
tuberculous  origin,  surgery  may  claim  even  further  contributions. 

Lacking  in  brilliancy  as  our  surgical  clinical  results  may  yet  be  regarded, 
we  have  not  been  unmindful  of  the  need  of  experimental  investigation,  and 


TUBERCULOSIS   OF    THE    LUNG   AND    PLEURA. ROBINSON.  75 

the  past  ten  years  have  witnessed  distinct  endeavors  in  this  direction.  The 
experimental  successes  of  Biondi,  Gluck,  and  Schmidt  in  1882,  and  there- 
abouts, were  followed  by  renewed  clinical  enthusiasm  and  apparent  experi- 
mental satisfaction.  The  clinical  hopes  aroused  by  the  results  of  these 
experiments  were  not  realized  in  the  following  twenty  years.  The  past  ten 
years  mark  renewed  experimental  work,  and  the  clinical  wave  of  enthusiasm 
is,  I  think,  again  starting.  Continued  experimental  and  clinical  cooperation 
is  now  to  be  hoped  for. 

In  1904  Sauerbruch  described  his  negative  pressure  cabinet  for  the  pre- 
vention of  lung  collapse  in  intrathoracic  operations.  With  this  apparatus 
we  are  all  familiar.  Then  followed  improvements  in  the  older  methods  of 
artificial  respiration.  Brauer,  Mayer,  Seidel,  F.  T.  Murphy,  Green,  ]\Iurray, 
and  Robinson  have  introduced  various  forms  of  apparatus  for  the  use  of 
compressed  air  in  preventing  lung  collapse — the  positive  pressure  method. 

With  the  use  of  one  of  these  pressure-difference  methods  many  animal 
operations  have  been  successfully  performed.  The  operations  on  man  under 
negative  and  positive  pressure,  though  watched  with  increasing  interest,  have 
yet  been  too  few  from  which  to  draw  comparison  between  results  with  and 
without  apparatus. 

Most  surgeons  have  seen  the  human  pleural  cavity  opened  wide  in  the 
absence  of  artificial  inflation,  without  seeing  the  onset  of  dyspneic  symptoms. 
Many  have  also  seen  grave  symptoms  arise  which  lead  to  fatality  either  during 
or  soon  after  the  operation.  J\Iany  of  both  classes  of  cases  are  recorded  in 
the  literature.  In  other  words,  no  man  can  prophesy  the  probable  resis- 
tance of  a  given  patient  to  the  effects  of  lung  collapse ;  in  fact,  Parascandelo 
even  ventures  to  state  that  it  is  a  matter  of  idiosyncrasy  of  the  patient. 
Petit  and  others  have  expressed  lack  of  sympathy  with  the  recent  interest 
in  the  use  of  pressure-difference  methods,  but  it  remains  for  them  to  prove 
that  some  of  the  intrapleural  operations  wliich  have  resulted  fatally  would 
not  have  terminated  otherwise  if  the  lung  collapse  had  been  avoided  by  the 
use  of  some  apparatus.  Even  should  my  opinion  prove  erroneous,  that 
eventually  some  simple  form  of  positive  pressure  apparatus  will  be  used  in 
most  pulmonary  operations,  nevertheless  the  advances  made  experimentally 
in  this  connection  have  contributed  much  to  the  further  development  of 
lung  surgery,  for  reasons  which  I  will  endeavor  to  point  out. 

The  animal  best  suited  for  experimental  thoracic  surgery  is  the  dog. 
A  large  opening  in  the  chest  of  this  animal  results  within  a  few  seconds  to 
four  minutes  in  death.  Before  the  development  of  these  improved  appara- 
tus for  artificial  inflation  the  best  experimental  investigations  reported 
were  done  without  apparatus.  An  Italian,  Biondi,  accomplished  surprising 
results  by  drawing  the  lung  out  of  the  chest  through  a  small  opening,  thus 
blocking  the  entrance  of  air  as  much  as  possible,  and  operating  on  the  lung 


76  SIXTH    INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

and  its  root  extrathoracically.  A  technic  was  thus  recommended  which  in 
the  normal  animal  was  moderately  successful.  I  have  at  times  experi- 
mented on  dogs  and  rabbits  in  this  way,  and  have  experienced  Biondi's 
difficulties  in  having  to  apply  constant  artificial  respiratory  pressure  on  the 
chest  and  epigastrium.  Blood-pressure  tracings  taken  at  the  time  demon- 
strated the  great  reflex  depression  from  traction  on  the  lung  root,  threatening 
the  animal  with  collapse.  To  perfect  the  surgery  of  the  human  chest,  in 
which  the  presence  of  adhesions  often  renders  the  delivery  of  the  lung  im- 
possible, an  intrathoracic  technic  is  essential.  Traction  and  manipulation, 
furthermore,  are  as  much  to  be  avoided  as  on  the  intra-abdominal  organs. 
To  operate  intrathoracically  and  thus  avoid  these  dangers,  the  pleural  open- 
ing must  be  large  and  wide,  especially  to  reach  the  lung  root. 

The  perfected  positive  pressure  methods  have  given  us  means  of  pre- 
venting lung  collapse,  at  least  in  animal  experimentation,  and  from  operations 
within  the  chest  a  new  intrathoracic  technic  has  been  developed.  The  chest 
opening  may,  as  suggested  by  Mikulicz,  be  made  ample  by  separating  the 
ribs  with  a  spreader  introduced  in  a  long  intercostal  incision.  Such  an 
opening  is  large  enough  to  admit  a  hand  for  complete  exploration  of  one  half 
of  the  pleural  cavity;  large  enough,  also,  for  thorough  and  painstaking 
operating  on  the  thoracic  viscera. 

Thoracic  surgery  in  animals  being  deprived  of  its  dangers  by  the  use  of 
apparatus,  numerous  pulmonary  operations  have  been  performed  by  experi- 
menters, and  although  pneumectomy  of  greater  or  less  portions  has  been  the 
popular  operation,  much  has  been  learned  in  this  connection  which  improves 
the  technic  of  chest  surgery  for  operations  other  than  excisions. 

Talke  has  shown  experimentally  the  processes  of  repair  of  lung-tissue 
after  operation  as  well  as  technical  measures  to  assure  the  best  healing. 

Mayer,  of  Brussels,  from  a  long  series  of  operations  on  the  dog,  has 
thrown  hght  on  the  dangers  of  air  embolism  and  thrombosis. 

Greene  and  Murray,  of  New  York,  and  Tiegel  have  demonstrated  the 
success  of  several  methods  of  closing  the  incised  lung  tissue. 

Friederich,  through  animal  experimentation,  points  out  the  importance 
of  accuracy  and  thoroughness  in  the  treatment  of  the  amputated  bronchus. 

Sauerbruch  has  investigated  the  cause  of  serious  symptoms  of  pneumo- 
thorax and  has  devised  the  negative  pressure  cabinet  to  avoid  them. 

My  own  experiments  have  been  devoted  to  the  improvement  of  technic 
of  intrathoracic  operating,  to  the  effects  of  traction,  incision,  compression, 
and  excision  of  lung  tissue,  both  as  to  pathology  and  blood-pressure.  In 
addition  to  sixty  operations  and  experiments  for  the  above  purpose,  G.  A. 
Leland  and  I  have  recently  completed  a  series  of  fifteen  operations  on  rabbits 
without  the  use  of  apparatus.  Total  lung  excisions  were  accomplished 
through  wide  openings.     Of  the  last  ten  animals  operated,  eight  are  now 


TUBERCULOSIS    OF   THE    LUNG    AND    PLEURA. ROBINSON.  77 

living  and  well.  The  lack  of  pneumothorax  symptoms  in  the  rabbit,  which 
are  fatally  present  in  all  dogs  operated  without  apparatus,  leads  to  an  in- 
vestigation of  the  comparative  structure  and  anchorage  of  the  mediastinum 
in  the  dog,  rabbit,  and  human  being.  Thus  I  hope  to  throw  further  light 
on  the  cause  of  fatal  pneumothorax. 

In  conclusion,  then,  I  would  say  that  despite  the  discouraging  cHnical 
results  of  pulmonary  surgery,  even  to  the  present  day,  the  experimental 
perfecting  of  pressure  apparatus  to  meet  the  undoubted  needs  of  certain 
cases,  and  the  experimental  improvement  in  the  general  technic  of  opera- 
tions within  the  chest,  justify  hope  that  surgery  soon  may  approach,  more 
skilfully,  tuberculous  cavities  and  tubercular  empyema,  though  lung  exci- 
sion may  never  prove  an  advisable  procedure;  and,  furthermore,  that  by 
pleural  incision  the  technic  of  nitrogen  injection  may  be  spared  the  dangers 
of  trocar  puncture,  and  that  plastic  operations  for  the  splinting  of  the  lung' 
may,  with  the  help  of  a  pressure-difference  apparatus,  be  done  more  thor- 
oughly and  with  less  danger  to  the  patient. 

DISCUSSION. 

Dr.  Emil  G.  Beck  (Chicago) :  The  future  of  surgical  treatment  of  the 
chest  is  promising.  Only  recently  I  have  been  shown  the  specimens  and  the 
results  from  experiments  on  dogs  by  Dr.  Opie,  at  the  Rockefeller  Institute 
of  New  York.  These  experiments  indicate  that  the  treatment,  by  injection 
of  white  blood-corpuscles  into  the  pleura  of  dogs  which  had  been  infected 
by  tuberculosis,  has  great  possibilities.  I  have  likewise  been  able  to  dem- 
onstrate on  patients  that  tuberculous  empyema  is  amenable  to  the  treat- 
ment of  bismuth  paste  injections,  and  I  believe  that  tuberculous  pleurisy, 
which  is,  in  most  cases,  an  early  compUcation  of  tuberculosis  of  the  lung, 
is  likewise  amenable  to  the  same  treatment. 

Dr.  H.  Berlin  (Chattanooga,  Tenn.)  said,  we  had  been  able  to  do  some- 
thing with  negative  pressure,  and  if  we  could  get  a  positive  pressure  appara- 
tus that  was  successful,  he  thought  we  would  be  able  to  do  much  more. 
Lung  abscesses  have  been  opened  by  this  method  successfully,  but  what 
could  we  expect  from  surgery  in  a  general  tuberculosis  of  the  lung?  We 
might  be  able  to  remove  one  or  even  two  lobes  of  a  lung,  as  had  already 
been  done  in  animals,  but  in  what  way  would  it  benefit  the  patient  with 
general  tuberculosis  to  have  this  done? 

Dr.  Robinson  said  he  thought  surgeons  often  credited  men  doing  ex- 
perimental work  with  undue  enthusiasm,  and  were  inclined  to  believe  that 
the  same  results  obtained  in  animal  experimentation  could  be  gotten  in  the 
human  subject.  Some  surgeons  had  said  to  him  that  they  had  opened  the 
pleural  cavity  without  any  apparatus,  and  they  did  not  see  the  need  of 
apparatus.     He  thought  such  men  believed  that  he  gave  undue  credit  to 


78  SIXTH   INTERNATIONAL   CONGRESS    ON   TUBERCULOSIS. 

the  apparatus  method.  Although  many  operations  had  been  done  without 
apparatus,  there  was  no  way  of  teUing  whether  the  patient  would  collapse 
on  opening  the  pleural  cavity,  and  it  seemed  to  him  that  it  was  our  duty  at 
least  to  have  ready  some  form  of  apparatus  to  prevent  that  collapse. 
The  rabbit  experiments  had  been  very  gratifying.  In  the  first  30  operations 
on  dogs  the  operations  consisted  in  removal  of  a  greater  or  less  portion  of 
the  lung,  and  out  of  the  30  operations  there  were  21  recoveries.  The  deaths 
were  largely  in  cases  where  an  attempt  had  been  made  to  remove  the  entire 
right  lung.  In  these  operations  it  was  absolutely  necessary  to  have  the 
apparatus  going.  If  it  broke,  the  animal  went  to  pieces  at  once.  By  pulling 
the  lung  into  the  opening  in  the  chest-wall  the  symptoms  of  collapse  could 
be  arrested.  A  great  deal  of  the  surgery  of  the  chest  in  the  last  fifty  years 
had  consisted  of  this  procedure.  In  his  experiments  with  rabbits  he  had 
first  begun  pulling  the  lung  out  through  a  small  opening,  but  the  lung  tore 
at  once,  because  of  its  delicate  structure.  Then  a  wide  and  long  intercostal 
incision  was  made,  a  ligature  was  put  around  the  lung  root,  and  it  was  then 
amputated.  After  two  operations,  one  day  the  apparatus  did  not  work 
very  well,  and  the  animal  seemed  to  do  just  as  well.  After  that  the  apparatus 
was  discarded.  The  animals  were  etherized,  and  the  chest  opened  widely. 
There  was  no  sign  of  dyspnea  during  an  operation  lasting  an  hour  and  a 
half.  In  the  first  few  he  was  not  familiar  with  etherizing  the  rabbits,  and 
he  lost  some  of  them  on  that  account,  but  of  the  last  ten  operated  on,  eight 
were  still  alive.  The  question  was,  "Which  do  the  human  tissues  most 
resemble,  those  of  the  rabbit  or  those  of  the  dog?"  He  was  convinced  that 
the  disastrous  result  in  dogs  was  due  to  the  mobility  of  the  mediastinum, 
which  was  not  the  case  with  the  rabbit.  In  the  rabbit  the  heart  seemed 
to  occupy  a  greater  portion  of  the  mediastinum  than  was  the  case  in  the  dog. 


Los  Aspectos    Quirurgicos    de  la    Tuberculosis  de  los  Pulmones  y  de 

la  Pleura. — (Robinson.) 

En  cuanto  a  los  progresos  en  la  curacion  y  prevencion  de  la  tuberculo- 
sis, la  Cirugia  ha  hecho  muy  poco  6  nada  en  este  punto.  No  solamente 
es  la  cirugia  intratoracica  caracterizada  por  un  progreso  lento  en  compa- 
racion  con  la  cirugia  de  las  otras  partes  del  cuerpo,  sino  que  los  resultados 
de  las  operaciones  de  las  lesiones  tuberculosas  en  la  cavidad  del  pecho, 
han  sido  tan  poco  satisfactorias,  que  no  dan  sino  una  esperanza  limitada  al 
operador  de  invadir  esta  region. 

La  literatura  nos  demuestra  los  resultados  poco  favorables  en  la  evacua- 
ci6n  de  las  cavidades  tuberculosas  por  medio  de  la  toracotomia,  las  con- 
diciones  generales  del  paciente  han  sido  tal  vez  temporariamente  mejoradas, 
mas  el  curso  de  la  enfermedad  ha  sido  raramente  detenido.     Se  sabe  de  cases 


TUBERCULOSIS    OF   THE    LUNG   AND    PLEURA. ROBINSON.  79 

en  los  cuales  la  neumectomia  parcial  6  completa  ha  abreviado  la  vida  del 
paciente,  bien  debido  al  efecto  immediato  de  la  operacion,  a  la  existencia 
de  neumotorax  despu^s  de  la  operacion  6  bien  al  colapso  del  pulmon  opuesto 
debido  a  lesiones  del  mediastino.  En  aquellos  pocos  casos  en  los  cuales  la 
operacion  se  ha  considerado  favorable,  una  terminacion  fatal  ha  sido  el 
resultado  debido  al  aumento  y  diseminacion  de  la  enfermedad  a  los  lobu- 
los  restantes  del  lado  operado  y  a  trasniision  del  material  infectado  al  lado 
opuesto. 

El  Siglo  Veinte  ha  ya  presenciado  un  avance  en  la  tecnica  de  la  cirugia 
intratoracica  por  medio  de  la  introducion  del  metodo  de  la  presion  negativa 
evitando  asi  los  peHgros  del  neumotorax  y  tambien  por  medio  del  per- 
feccionamiento  del  metodo  de  la  presion  positiva  para  evitar  estos  peligros. 
Las  investigaciones  de  Sauerbruch,  Brauer,  Matas,  Smithe,  Greene,  Janeway, 
Mayer,  Tuffier,  Seidel  y  las  del  autor,  han  demostrado  que  una  toracotomia 
exploratoria,  a  la  ayuda  de  los  nuevos  metodos  presenta  tan  pocos  peligros 
como  una  laparotomia  exploratoria.  Los  investigadores  mencionados 
estaran  tambien  de  acuerdo  en  que  la  extirpacion  parcial  6  completa  de  una 
6  dos  lobulos  de  cualquiera  de  los  pulmones  es  una  operacion  de  poco  peligro 
para  el  paciente.  Este  ultima  conclusion  est  a  basada  principalmente  en 
los  experimentos  hechos  con  los  animales,  mas  es  bien  sabido  que  el  pulmon 
del  hombre  esta  menos  espuesto  a  la  infeccion  y  es  menos  suceptible  a  los 
peligros  del  neumotorax  que  la  mayor  parte  de  los  animales  usados  en  los 
experimentos.  El  mediastino  del  hombre  es  comparativamente  una  estruc- 
tura  inaccesible,  las  condiciones  del  lado  opuesto  a  la  operacion  no  son  tan 
desfavorables  como  lo  son  en  el  perro. 

Dado  el  caso  de  estos  nuevos  procedimientos  justificables  en  la  toraco- 
tomia exploratoria  6  neumectomia  parcial,  que  se  puede  decir  en  cuanto 
al  6xito  de  la  cirugia  en  la  tuberculosis  pulmonar?  Un  numero  insufi- 
ciente  de  casos  han  sido  operados  por  los  nuevos  metodos  para  poder  sacar 
de  ellos  una  conclusion  definida.  Por  desgracia  los  casos  mas  apropiados 
para  el  tratamiento  operatorio,  son  aquellos  en  los  cuales  por  lo  general 
los  mismos  resultados  favorables  pueden  obtenerse  por  medio  del  trata- 
miento higienico.  Yo  me  refiero  a  aquellos  casos  de  focos  aislados  y  limita- 
dos  a  uno  6  dos  lobulos  del  pulmon.  Por  medio  de  los  rayos  X,  tales  casos  son 
f acilmente  reconocidos  aun  antes  de  que  los  signos  fisicos  sean  diagnosticables, 
mas  tales  casos  no  llegan  a  las  manos  del  m6dico  sino  es  hasta  despues  de 
haber  recurido  al  tratamiento  general.  Habiedo  fracasado  en  el  trata- 
miento general,  debido  a  la  extension  de  la  infeccion,  el  caso  es  menos 
adecuado  a  la  escision  de  la  area  afectada,  ademas  hay  el  peligro  de  la  ex- 
tension de  la  affeci6n  a  los  otros  lobulos  6  bien  la  trasmision  directa  del 
material  infectado  al  lado  opuesto. 

En  otras   palabras,  no  puede  decirse  que  la  tuberculosis  del  pulmon 


80  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

esta  fuera  del  alcance  del  cirujano,  mas  el  problema  qiieda  por  resolverse 
si  el  drenage  6  escision  del  foco  tuberculoso  en  la  cavidad  toracica  pueda 
producir  la  desaparicion  de  la  infeccion.  Es  de  espararse  a  la  menos  que 
el  tratamiento  por  medio  de  la  vacuna  y  las  medidas  higienicas,  despues  de 
la  evacuacion  del  material  infectado  por  medio  de  la  operacion  lleguen  a  dar 
mejores  resultados. 


Die  Aussichten  fiir  chirurgische  Behandlung  der  Tuberculose  der 
Lungen  und  der  Pleura. — (Robinson.) 

In  Bezug  auf  die  Fortschritte  in  der  Behandlung  und  Verhiitung  der 
Tuberculose  kann  die  Chirurgie  sehr  wenig  oder  gar  keine  Anspriiche  auf 
Verdienste  machen.  Nicht  nur  ist  die  Geschichte  der  Brusthohlen-Chirurgie 
durch  einen  langsameren  Fortschritt  als  die  Chirurgie  irgend  einer  anderen 
Region  des  Korpers  ausgezeichnet,  sondern  auch  in  Bezug  auf  Lasionen 
innerhalb  der  Brusthohle  selbst  haben  sich  diejenigen  von  tuberculoser 
Beschaffenheit  besonders  hinsichtlich  chirurgischer  Eingriffe  unzufrieden- 
stellend  gezeigt.  Es  ist  deshalb  sehr  wenig  ermuthigend  fiir  den  Operateur, 
sich  an  diese  Region  heranzuwagen. 

Die  aus  der  Literatur  bekannten  Falle  von  Drainirung  tuberculoser 
Hohlen  durch  Thoracotomie  sind  ziemlich  entmuthigend.  Die  Kranken 
fanden  allerdings  zeitweilig  Erleichterung,  aber  nur  selten  konnte  die 
Krankheit  zum  Stillstand  gebracht  werden.  Es  sind  einige  Falle  von 
partieller  oder  totaler  Pneuraectomie  veroffentlicht,  in  denen  das  Leben 
der  Kranken  abgekiirzt  wurde,  entweder  durch  Schlag  von  der  Operation, 
oder  durch  Bildung  eines  Pneumothorax  nachdem  die  Brust  geschlossen 
wurde,  oder  durch  Collabirung  der  Lunge,  an  der  nicht  operirten  Seite, 
durch  Verw^undung  des  Mediastinums.  In  den  wenigen  Fallen,  wo  der 
operative  Eingriff  als  erfolgreich  bezeichnet  werden  konnte,  wurde  ein 
todtlicher  Ausgang  durch  Verstarkung  und  Ausbreitung  der  Krankheit  in 
den  zuriickgebliebenen  Lappen  an  der  geoffneten  Seite  und  durch  Uber- 
tragung  des  Infectionsmaterials  auf  die  andere,  nicht  operirte  Lunge  be- 
obachtet. 

Ein  weiterer  Fortschritt  in  der  Technic  der  intrathoracalen  Chimrgie 
ist  bereits  in  unserem  (zwanzigsten)  Jahrhundert  erfolgt  durch  die  Ein- 
fiihrung  der  Methode  des  negativen  Druckes  zur  Vermeidung  der  Gefahr  des 
Pneumothorax,  und  durch  Vervollkommnung  der  Methode  des  positiven 
Druckes  um  dieser  Gefahr  vorzubeugen.  Die  Untersuchungen  von  Sauer- 
bruch,  Brauer,  Matas,  Smythe,  Greene,  Janeway,  Mayer,  Tuflfier,  Seidel  und 
meine  eigenen  haben  bewiesen,  dass  die  nach  den  neuen  Methoden  zu  Unter- 
suchungszwecken  ausgeflihrte  Thoracotomie  mit  keiner  grosseren  Gefahr 
verbunden  ist,   als  die   zu  demselben  Zwecke  ausgeflihrte   Laparotomie 


TUBERCULOSIS    OF    THE    LUNG    AND    PLEURA. ROBINSON.  81 

Die  genannten  Forscher  wiirden  auch  darin  iibereinstimmen,  dass  eine  par- 
tielle  oder  vollstandige  Entfernung  von  einem  oder  zwei  Lappen  einer 
Lunge  als  eine  Operation  angesehen  werden  kann,  die  mit  wenig  Gefahr  flir 
den  Kranken  verbunden  ist.  Dieser  Schluss  ist  hauptsachlich  auf  Thier- 
versuche  gegriindet,  aber  es  ist  eine  bekannte  Thatsache,  dass  der  mensch- 
liche  Thorax  viel  weniger  zu  Infection  geneigt  ist  und  weniger  der  Gefahr 
eines  Pneumothorax  ausgesetzt  ist  als  es  bei  den  meisten  der  Versuchsthiere 
der  Fall  ist.  Da  das  menschliche  Mediastinum  von  verhaltnissmassig 
nachgiebigerer  Beschaffenheit  ist,  so  liegen  die  Verhaltnisse  in  Bezug  auf 
die  nicht  geoffnete  Seite  des  Thorax  nicht  so  ungiinstig,  wie  es  z.  B.  beim 
Hunde  der  Fall  ist. 

Wenn  wir  nun  auch  die  neuen  Eingriffe  der  Thoracotomie  fiir  Unter- 
suchungszwecke  oder  fiir  partielle  Pneumectomie  als  berechtigt  anzusehen 
haben,  so  entsteht  weiterhin  die  Frage :  Was  konnen  wir  iiber  die  Aussichten 
chirurgischer  Eingriffe  bei  Lungentuberculose  voraussagen?  Seit  der 
Vervollkommnung  der  neuen  Methoden  war  leider  die  Zahl  der  Falle,  die 
zur  Operation  gelangten,  zu  ungeniigend,  um  daraus  irgend  welche  Schliisse 
zu  Ziehen.  Es  ist  auch  zu  bedauern,  dass  solche  Falle,  die  sich  fiir  chirui- 
gische  Eingriffe  am  besten  eignen  wiirden,  eben  auch  diejenigen  sind,  bei 
denen  man  sich  von  einer  hygienischen  Behandlung  ebenfalls  die  meisten 
Erfolge  versprechen  kann.  Ich  habe  hier  diejenigen  Falle  im  Auge,  wo  wir 
es  mit  isolirten  Heerden,  auf  einen  oder  zwei  Lungenlappen  beschrankt, 
zu  thun  haben.  Mit  Hiilfe  der  X-Strahlen  konnen  solche  Falle  diagnosticirt 
werden,  lange  vorher,  ehe  irgend  welche  physikalischen  Zeichen  zum  Vor- 
schein  kommen,  aber  der  innere  Mediziner  v.drd  lange  zogern,  ehe  er  diese 
FtiUe  dem  Chirurgen  zur  Behandlung  iiberlassen  wird,  ohne  vorher  eine 
allgemeine  Behandlung  versucht  zu  haben.  Hat  sich  letztere  mit  der  Zeit 
als  erfolglos  erwiesen,  so  hat  sich  dann  auch  der  Fall  unterdessen  aber  zu 
einem  weniger  geeigneten  fiir  eine  totale  Entfernung  des  Krankheitsheerdes 
gestaltet,  weil  mittlerweile  eine  Ausbreitung  der  Infection,  ein  Mitange- 
griffensein  der  anderen  Lappen,  und  sogar  vielleicht  eine  IJbertragung  der 
Krankheit  auf  die  andere  Lunge  stattgefunden  hat. 

Mit  anderen  Worten,  es  kann  jetzt  nicht  mehr  mit  Recht  behauptet 
werden,  dass  die  Tuberculose  der  Lungen  und  der  Pleura  sich  ausserhalb  des 
Bereiches  der  Chirurgie  befindet,  aber  die  Frage  bleibt  noch  offen,  ob  durch 
Drainirung  der  Brusthohle  oder  durch  Entfernung  von  tuberculosen  Heerden 
aus  derselben  jemals  die  Infection  selbst  entfernt  werden  kann. 

Indessen  ist  wenigstens  die  Hoffnung  vorhanden,  dass  die  Krankheit 
durch  Impfung  und  hygienische  Behandlung  mit  mehr  Erfolg  wiirde  be- 
kampft  werden  konnen,  wenn  gleichzeitig  etwa  bestehende  grossere  Ansamm- 
lungen  von  Infectionsmaterial  von  dem  Chirurgen  entweder  drainirt  oder 
entfernt  worden  sind. 


DIE    CHIRURGISCHE    BEHANDLUNG    DER    LUNGEN- 

TUBERKULOSE. 

Von  F.  Sauerbruch, 

Marburg,  DeutschlaQd. 


Die  Versuche,  auf  chirurgischem  Wege  die  Lungentuberkulose  in  Angriff 
zu  nehmen,  datieren  seit  Hosiers  (1873)  parenchymatosen  Injektionen  von 
Carbol-  imd  Salicjdsaure  in  die  Lunge.  Derselbe  Autor  eroffnete  dann  auch 
mit  Hueter,  als  erster,  eine  bronchiectatisclie,  tuberkulose  Caverne.  Dem- 
nach  war  Hosier  der  erste,  der  eine  chirurgische  Behandlung  der  Tuberkulose 
in  das  Bereich  der  IMoglichkeit  zog.  Diese  Versuche  aktiver  chirurgischer 
Therapie  fanden  sehr  wenig  Anerkennung,  und  wurden  nur  von  wenigen 
nachgemacht.  Han  hatte  eben  gelernt,  die  Tuberkulose  nicht  nur  als  ein 
lokales,  durch  das  Eindringen  von  "Keimen"  an  bestimmten  Stellen  her- 
vorgerufenes  Leiden  anzusehen,  sondern  als  eine  mehr  oder  weniger  aus- 
gebreitete  Allgemeinerkrankung. 

Hosiers  Vorgehen  beruhte  dagegen  auf  der  Vorstellung,  dass  es  gelingen 
miisse  durch  Injektion  antiseptischer  Fliissigkeiten,  wie  Carbol-  und  Salicyl- 
saure,  die  in  den  Lungengeweben  sitzenden  Injektionserreger  abzutoten. 
Ahnlich  wie  ]\Iosler  hat  dann  spater  W.  Pepper  Jodkalilosung  und,  nach  der 
Entdeckung  des  Tuberkelbazillus,  lodoformol  eingespritzt.  Wir  wissen 
heute,  dass  eine  Wirkung  von  solchen  Injektionen  nicht  erwartet  werden 
kann.  Die  Erfolge  dieser  Behandlung  waren  sehr  gering.  Einigemale 
erfolgte  Verminderung  der  Sekretion.  In  den  meisten  dieser  Falle  konnte 
aber  diese  Besserung  nicht  konstatiert  werden. 

Den  zweiten  Anstoss,  die  erkrankte  Lunge  auf  operativem  Wege  zu 
heilen,  gaben  dann  im  Jahre  1881  die  Versuche  von  Gluck,  H.  Schmidt, 
Block,  denen  es  gelang,  an  Tieren  Telle  der  Lunge  zu  resezieren,  ja  sogar 
die  Lunge  einer  Seite  zu  extirpieren  mit  voriibergehender  Erhaltung  des 
Lebens  der  Tiere. 

Biondi  baute  auf  diesen  Versuchen  weiter,  impfte  bazillenhaltiges  Ha- 
terial  in  die  Lungen  der  Tiere,  und  erzeugte  so  eine  Tuberkulose  der  Lunge, 
welche  eine  Zeit  lokal  blieb.  Diese  lokale  Tuberkulose  beseitigte  er  dann 
dadurch,  dass  er  die  kranke  Lunge  extirpierte.  Er  konnte  bei  einzelnen 
Tieren,  die  nicht  an  den  direkten  oder  indirekten  Folgen  der  Operation 

82 


LUNGENTUBERKULOSE,    CHIRURGISCHE    BEHANDLUNG. — SAUERBRUCH.       83 

starben,  beobachten,  class  mit  der  Entfernung  der  erkrankten  Lunge  die 
Tuberkulose  aus  dem  Korper  beseitigt  war. 

Der  Erste,  der  dann  auch  beim  ^lenschen  die  Resektion  erkrankter 
Lungenabschnitte  versucht  hat,  war  der  Amerikaner,  Block;  bald  darauf 
folgte  ihm  Ruggi;  der  Ausgang  dieser  Operationen  war  schlecht — die 
Patienten  starben. 

Tuffier  hat  spater  einen  nussgrossen,  tuberkulosen  Herd  der  rechten 
Lungenspitze,  ohne  Eroffnung  der  Pleura,  und  ohne  Rippenresektion 
durch  den  zweiten  Intercostalraum  hindurch  excidiert.  Der  Patient  war 
noch  nach  \'ier  Jahren  gesund.  Reclus  citiert  noch  vier  totlich  verlaufene 
Falle,  Doyen  einen  geheilten,  bei  welchem  er  ein  kleinfaustgrosses  Stiick 
der  Lunge  entfernt  hatte. 

Auch  Sonnenburg,  der  die  i\IosIer'sche  Injektion  mit  der  Resektion  ver- 
band,  hatte  wenig  erfolgreiche  Resultate. 

Ein  anderes  Ziel  hatten  die  Arbeiten  von  Koch,  Rochelt,  Tuffier,  Kurz, 
Reclus,  und  Quincke.  Sie  beschaftigten  sich  mit  der  Behandlung  derjenigen 
Formen  der  Tuberkulose,  bei  denen  es  zu  Cavernenbildung  gekommen  war, 
und  wo  die  Stagnation  des  Secretes  in  der  starrwandigen  Hohle  im  Vorder- 
grund  des  Krankheitsbildes  stand.  Das  gegebene  Verfalii'en  war  die  opera- 
tive Eroffnung  der  Caverne  und  Drainage  derselben.  Aber  von  27  von 
Tuffier  im  Jahre  1897  zusammengestellten  Fallen  hat  allein  einer,  ein  von 
Sonnenburg  1891  operierter  und  gleichzeitig  mit  TuberkuHn  behandelter 
Patient,  den  volligen  Dauererfolg  erzielt. 

Nach  einer  zweiten  Zusammenstellung  von  Rouenberg  und  einer  weiteren 
von  Lopez  sind  noch  19  derartige  Cavernenoffnungen  vorgenommen  worden, 
aber  alle  nur  mit  voriibergehender  Besserung;  alle  sind  letal  verlaufen. 

Prinzipiell  andere  Unterlagen  haben  dann  Quincke  und  Spengler  fiir 
die  operative  Behandlung  starrwandiger  Cavernen  geschaffen.  Ihre  i\Iethode 
sttitzt  sich  auf  die  pathologisch-anatomische  Tatsache,  dass  tuberkulose 
Lungenherde  bei  der  natiirlichen  Heilung  durch  Schrumpfung  und  Nar- 
benbildung  verschwinden  konnen. 

Schon  1888  (Berliner  klinische  Wochenschrift,  Nr.  18)  schlug  Quincke 
vor,  bei  tuberkulosen  Hohlen  der  Lunge  die  niichstliegenden  Telle  der 
Brustwand  zu  entfernen,  dadurch  die  Lunge  zu  mobilisieren,  und  auf  diese 
Weise  eine  Narbenretraktion  zu  ermoglichen.  Quincke  selbst  hat  diese 
Operation  nicht  ausgefiihrt.  Zu  ahnlichen  tlberlegungen  kam,  unabhangig 
von  Quincke,  Spengler.  Dieser  Autor  konnte  sogar  auf  dem  Naturforscher- 
tag  in  Bremen  1890  bereits  iiber  einen  giinstigen  Erfolg  dieser  Behandlung 
berichten;  1894  operierte  dann  auch  Bier  bei  einer  isoUerten  Lungencaverne 
der  rechten  Spitze  nach  dieser  Methode,  d.  h.  mit  der  Absicht,  durch  aus- 
giebige  Mobilisation  der  Brustwand  eine  dauernde  Schrumpfung  der  Lunge 
herbeizufiihren.     Ferner   haben   Turban   und   Landerer   durch   ausgiebige 


84  SIXTH   INTERNATIONAL   CONGRESS    ON   TUBERCULOSIS. 

Rippenresektion  die  Brustwand  nachgiebig  gemacht,  und  durch  dieses 
Vorgehen  Besserungen  erzielt.  Ich  selbst  assistierte,  1904,  v.  Mikulicz 
im  Sanatorium  von  Turban  als  er  auf  dessen  Indikation  eine  vernehmlich 
einseitige  Lungentuberkulose  operierte.  Mikulicz  machte  eine  gi'ossere 
Thorakoplastik  (Resektion  von  5  oder  6  Rippen).  Trotz  Verletzung  des 
Brustfelles  iiberstand  die  junge  Patientin  den  Eingriff,  lebte  allerdings  nur 
noch  dreiviertel  Jahre,  bis  sie  an  ihrer  Tuberkulose  zu  Grunde  ging. 

Eine  andere  ]\Iethode,  die  Tuberkulose  durch  chirurgische  Massnahmen 
zu  behandeln,  stammt  von  Murphy.  Er  ging  von  der  Vorstellung  aus, 
dass  die  ruhig  gestellte  und  unter  andere  Cirkulationsbedingung  gebrachte 
Lunge  ganz  iilinlich  wie  ruhig  gestellte  Gliedmassen  eher  ausheilen  miisste, 
als  die  arbeitende.  Diese  Ruhigstellung  suchte  er  dadurch  zu  erreichen, 
dass  er  unter  einem  massigen  Druck  Stickstoff  in  die  Brusthohle  einblies, 
einen  kiinstlichen  Pneumothorax  erzeugte,  und  dadurch  die  Lunge  zum 
Collaps  brachte. 

Nach  Murphy  hat  der  Italiener  Forlanini  an  einer  grosseren  Zahl  von 
Patienten  das  Verfahren  erprobt,  und  iiber  giinstige  Erfolge  berichten 
konnen. 

In  Deutschland  hat  Brauer  ganz  besonders  dieses  Verfahren  ausgear- 
beitet,  und  an  einer  grossen  Anzahl  von  Patienten  die  Leistungsfahigkeit 
desselben  erwiesen. 

Das  ist  in  kurzen  Umrissen  die  Geschichte  der  Entwicklung  der  Chirurgie 
der  Lungentuberkulose.  Abgesehen  von  den  letzten  Versuchen,  "Pneu- 
mothorax und  Thorakoplastik,"  auf  die  ich  noch  ausfiihrlich  zu  sprechen 
komme,  sind  alle  Bemiihungen,  die  Lungentuberkulose  chirurgisch  zu 
beeinfiussen,  wenig  erfolgreich  gewesen.  Aber  insofern  haben  sie  Friichte 
getragen,  als  sie  uns  die  Grenzen  zeigten  innerhalb  deren  iiberhaupt  der 
Versuch  einer  operativen  Therapie  gerechtfertigt  erscheint. 

Fiir  eine  richtige  Beurteilung  des  Wertes  einer  jeden  Behandlung  der 
Tuberkulose  ist  die  Tatsache  von  Wichtigkeit,  dass  jede  Erkrankung, 
selbst  ein  umschriebener  lokaler  Herd,  der  Ausdruck  einer  Allgemeininfek- 
tion  ist.  Eine  "lokale"  Erkrankung  ohne  gleichzeitige  Beteiligung  des 
Gesamtorganismus  gibt  es  nicht.  Jede  Therapie,  auch  die  operative, 
muss  diese  Tatsache  durchaus  beriicksichtigen.  Daher  soil  die  chirurgische 
Behandlung  der  Tuberkulose  immer  verbunden  sein  mit  klimatischer  und 
diatetischer  Allgemeinbehandlung,  mit  ihren  bekannten  mannigfachen 
Mitteln.  Andererseits  wissen  war  bestimmt  dass  die  Verbreitung  und 
Weiterentwickelung  der  "lokalen"  Tuberkulose  durch  operative  Beseitigung 
des  Hauptherdes  sich  verhindern  lasst.  Gleichzeitig  erzielen  wir  dadurch 
regelmassig  eine  betrachtliche  Hebung  des  Allgemeinzustandes,  und  nicht 
selten  eine  vollige  Ausheilung  der  Tuberkulose  iiberhaupt.  Das  zeigen  vor 
alien  Dingen  einwandsfrei  die  Erfahrungen  mit  der  chirurgischen  Behand- 


LUNGENTUBERKULOSE,    CHIRURGISCHE   BEHANDLUNG. — SAUERBRUCH.      85 

lung  der  Knochen-  und  Gelenktuberkulose.  Diese  schonen  Erfolge  haben 
eine  imbedingte  Voraussetzung: 

Die  Durchfuhrung  der  Operatioji  im  gesunden  Gewebe. — Wo  diese  nicht 
gelingt,  weil  die  Ausbreitung  des  tuberkulosen  Herdes  diffus  und  nicht  scharf 
begrenzt  ist,  so  dass  wir  selbst  durch  ausgedehnte  Resektion  das  erkrankte 
Gewebe  nicht  radikal  entfernen  konnen,  da  schaffen  wir  durch  sekundare 
Mischinfektion,  chronische  Eiterung  und  Fistelbildung  oft  sogar  schlech- 
tere  Verhaltnisse.  Der  Vergleich  der  Lungentuberkulose  mit  der  Tuber- 
kulosQ  der  Knochen  und  Gelenke  ist  naheUegend.  Von  vornherein  lasst 
sich  gegen  den  chirurgischen  Standpunkt,  eine  umschriebene  "lokale" 
Tuberkulose  der  Lunge  genau  so  zu  behandeln,  wie  eine  isoHerte  Gelenk-  oder 
Knochentuberkulose,  d.  h.  durch  operative  Beseitigung  des  Krankheitsherdes, 
nichts  prinzipielles  vorbringen.  Voraussetzung  ist  aber  hier  wie  dort,  dass 
es  uns  geUngt,  die  Abtragung  des  erkrankten  Gewebes  im  gesunden  vorzu- 
nehmen.  So  leicht  die  Wegnahme  der  erkrankten  Partien  in  den  meisten 
Fallen  der  Tuberkulose  von  Knochen  und  Gelenken  gelingt,  so  schwierig,  ja 
unmoglich,  kann  bei  der  Lungentuberkulose  dieser  Forderung  geniigt  werden. 

Wir  wissen  auf  Grund  pathologisch-anatomischer  Beobachtungen,  dass 
eine  "lokale"  Tuberkulose  der  Lungen,  d.  h.  ein  scharf  umschriebener  Herd, 
der  sich  vom  gesunden  sicher  abtrennen  lasst,  sehr  selten  ist.  Wenn  liber- 
haupt,  so  diirfte  er  wohl  nur  im  Beginn  der  Erkrankung  bei  der  sogenannten 
Infiltration  der  Spitzen  beobachtet  werden.  Alle  weiter  fortgeschrittenen 
Falle  mit  kasigem  Zerfall,  oder  gar  mit  Hohlenbildung,  sind  wohl  nur  selten 
auf  eine  Lunge  oder  gar  einen  Lappen  beschrankt.  Hier  kann  von  einer 
"lokalen"  Tuberkulose  demnach  sicherlich  keine  Rede  mehr  sein.  Es 
wiirde  sich  also  bei  einer  radikalen  Entfernung  eines  tuberkulosen  Krank- 
heitsherdes in  der  Lunge  nur  um  die  erkrankte  Spitze  handeln  konnen.  Die 
Frage  der  Radikaloperation  der  Lungentuberkulose  deckt  sich  demnach 
mit  der  Frage  der  Resektion  der  Lungenspitze.  Ihre  Entscheidung  ist  in 
erster  Linie  abhangig  von  der  Moglichkeit,  die  Abtragung  der  Spitze  im 
gesunden  vorzunehmen,  d.  h.  so  dass  sicherlich  nicht  der  geringste  tuber- 
kulose Herd  zuriickbleibt.  Damit  habe  ich  aber  schon  ausgesprochen,  wie 
selten  wir  geeignete  Fiille  finden  werden.  Trotz  unserer  verbesserten  Unter- 
suchungstechnik,  speciell  durch  das  Rontgenverfahren,  sind  wir  nicht  in  der 
Lage,  vorher  genau  die  Ausdehnung  eines  tuberkulosen  Infiltrates  der 
Spitze  festzustellen.  Wahrend  der  Operation  selbst  gelingt  eine  zuver- 
lassige  Abgrenzung  des  erkrankten  vom  gesunden  Gewebe  erst  recht  nicht. 
Die  Gefahr,  im  tuberkulosen  Gebiet  zu  operieren  ist  also  gross,  und  damit 
der  Erfolg  der  Operation  sehr  stark  in  Frage  gcstellt. 

Auch  die  Operation  selbst  ist  kein  kleiner  Eingriff.  Die  Gefahr  der 
Pleuraeroffnung  ist  zwar  wegen  der  meist  bestehenden  Verwachsung  nicht 
gross,  und  wiirde  bei  Anwendung  des  Druckdifferenzverfahrens  nur  geringe 


86  SIXTH    INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

Bedeutung  haben.  Aber  die  Abtragung  der  Spitze  fiihrt  zu  Blutung,  und 
die  Blutung  zu  Aspiration,  die  ihrerseits  mancherlei  Komplikationen  im 
weiteren  Verlauf  zur  Folge  haben  kann.  Wurde  bei  der  Operation  aus- 
serdem  noch  im  tuberkulosen  Gewebe  operiert,  so  kann  selir  leicht  von  liier 
aus  eine  Propagierung  des  Prozesses  eintreten. 

Mit  diesen  Uberlegungen  im  Einklang  stehen  die  bisherigen  Erfolge,  die 
keineswegs  ermutigend  sind.  Karenski  berichtet  iiber  10  Falle  aus  der 
Literatur,  von  denen  3  unmittelbar  nach  der  Operation  totlicli  endeten. 
Es  sind  die  Falle  von  Block  und  Ruggi.  Hinzu  kommen  4  weitere  totlich 
verlaufene  Falle  von  Reclus.  Diesen  7  Fallen  mit  ungliicklichem  Ausgang 
stehen  3  dauernd  geheilte  gegeniiber.  Es  sind  die  Patienten  von  Tuffier, 
Lawson,  und  Doyen.  Die  Mortalitat  ist  also  eine  ganz  betrachtliche.  Drei 
auf  operativem  Wege  geheilte  Falle  von  Lungentuberkulosev  erschwinden 
gegeniiber  der  grossen  Zahl  von  Patienten,  die  jahrlich  einer  regelrecht 
durchgefiihrten  klimatischen,  diatetischen  Allgemeinbehandlung  ihre  dau- 
ernde  Genesung  verdanken.  Kein  Arzt  kann  sich  der  Tatsache  verschliessen, 
dass  eine  beginnende  Spitzentuberkulose,  friihzeitig  erkannt,  auf  konser- 
vativem  Wege,  eventuell  in  Verbindung  mit  der  Tuberkulinbehandlung,  grosse 
Chancen  zur  Spontanheilung  hat.  Das  lehrt  uns  unzweideutig  die  kUnische 
Erfahrung,  und  das  zeigen  uns  vor  alien  Dingen  die  vielen  ausgeheilten 
Spitzenherde,  die  wir  so  haufig  auf  dem  Sectionstisch  als  Nebenbefund  in 
den  Lungen  von  Patienten  finden,  die  an  einer  anderen  Krankheit  zu  Grunde 
gegangen  sind. 

Der  Resektion  der  Lungenspitze  wiirde  selbst  dann  die  Berechtigung 
abzusprechen  sein,  wenn  sie  technisch  leichter  und  gefahrlos  ware.  Die 
chirurgische  Therapie  soil  erst  dort  einsetzen,  wo  die  interne  Behandlung 
versagt,  oder  wo  ein  operativer  Eingriff  mehr  leistet,  als  jene  vermag. 

Eine  prinzipiell  andere  therapeutische  Bedeutung,  als  die  Radikalopera- 
tion  der  Lungentuberkulose,  hat  die  Pneumotomie  bei  tuberkulosen  Caver- 
nen.  Sie  verzichtet  auf  eine  radikale  Beseitigung  des  tuberkulosen  Pro- 
zesses, und  hat  ausschliesslich  zum  Ziel,  die  sich  in  der  Hohle  ansammelnden 
Eitermengen  nach  aussen  abzuleiten,  und  eventuell  eine  Behandlung  der 
Hohlenwand  selbst  zu  ermoglichen.  Das  Vorgehen  lehnt  sich  eng  an  das- 
jenige  an,  welches  von  Quincke  und  Garre,  Korte,  Lenhartz  fiir  die  chro- 
nischen  Lungenabscesse  ausgearbeitet  worden  ist.  Genau  wie  dort,  wird 
nach  Verlotung  der  Lunge  mit  der  Brustwand  durch  Eroffnung  der  Cavernen 
mit  dem  Thermocauter  ein  Kanal  geschaffen,  durch  den  der  Caverneninhalt 
nach  aussen  abfliessen  kann.  Garre  prazisiert  die  Behandlung  chronischer 
Lungenabscesse  dahin,  dass  dieselben  wie  andere  starrwandige  Eiterhohlen 
zu  behandeln  sind.  "Das  Lungengewebe  wird  ausfiihrlich  gespalten,  die 
Wand  der  Caverne  moglichst  abgetragcn,  Pleuraschwarten  im  breiten 
Umkreis  reseziert,  und,  wenn  notig,  auch  eine  Nachresektion  der  Rippen 


LUNGENTUBERKULOSE,    CHIRURGISCHE    BEHANDLUNG. — SAUERBRUCH.      87 

hinzugefiigt.  Man  reseziere  lieber  eine  Rippe  zu  viel  als  zu  wenig."  Avich 
bei  tuberkulosen  Cavernen  wird  man  durch  Pneumotomie  die  Hohle  eroffnen 
und  drainieren,  dagegen  auf  alle  Eingriffe,  die  eine  vollstandige  Beseitigung 
der  Caverne  erzielen,  verzichten.  Es  diirfte  sich  empfehlen,  diese  Eroffnung 
prinzipiell  zweiseitig  zu  machen,  und  zwar  in  der  Form,  wie  es  neuerdings 
Perthes  besonders  empfohlen  hat.  Der  erste  Akt,  die  Rippenresektion  und 
die  eventuelle  Naht  der  Pleurablatter,  erfolgt  am  besten  in  Narkose  bei 
leerem  Zustand  des  Abscesses.  Der  zweite  Akt,  der  mehrere  Tage  darauf 
folgt,  soil  ohne  Narkose  vorgenommen  werden.  Er  besteht  in  der  Probe- 
punktion  des  Abscesses  von  der  Wunde  aus  und  in  seiner  Eroffnung. 

Schon  die  chronischen  Lungenabscesse  haben  im  Vergleich  zu  den  Er- 
folgen  bei  den  akuten  eine  sehr  schlechte  Prognose.  Aber  noch  ungiinstigere 
Resultate  hat  die  Eroffnung  tuberkuloser  Cavernen.  Das  hangt  einmal 
von  dem  schlechten  Allgemeinzustand  der  Phthisiker  ab.  Hinzu  kommt  als 
ein  Haupthindernis  fiir  die  Ausheilung,  dass  es  sich  meist  nicht  um  eine 
einzige  isolierte,  sondern  um  multiple,  oft  nicht  einmal  miteinander  in  Ver- 
bindung  stehende,  Hohlen  in  der  Lunge  handelt.  Schliesslich  ist  die  Hohlen- 
wand  selbst  und  das  umgebende  Lungengewebe  von  tuberkuloser  Infiltration 
durchsetzt  und  bietet  so  einen  Zustand,  dem  alle  Fahigkeiten  zur  Ausheilung 
fehlen.  Damit  wird  auch  die  operative  Behandlung  der  Hohlenwand,  wie 
sie  Garre  mit  dem  Messer,  und  Korte  mit  dem  Paquelin,  bei  chronischen 
Lungenabscessen  mit  Erfolg  anwandten,  unmoglich.  Es  bleibt  nach  der 
Operation  immer  eine  stark  secernierende  Lungenfistel  bestehn,  es  kommt 
zu  IMischinfektionen,  und  die  chronische  Eiterung  aus  der  Fistel  bringt  die 
Patienten  schneller  herunter,  als  der  tuberkulose  Prozess  selbst  es  tat. 

Anders  steht  es  bei  denjenigen  Fallen,  bei  denen  durch  Stagnation  des 
Hohlensekretes  und  jauchigen  Zerfall  eine  Resorption  putrider  Stoffe  mit 
hohem  Fieber  und  Intoxikationserscheinungen  zustande  kommt.  Hier  kann 
man  von  der  Eroffnung  der  Caverne  eine  schnellere  Entleerung  der  Hohle 
und  Verhindemng  der  gefahrlichen  Aufnahme  der  Giftstoffe  in  den  Organis- 
mus  erhoffen;  aber  selbst  dieser  Vorteil  wird  von  einem  so  erfahrenen 
Kliniker  wie  Quincke  gering  geschatzt,  weil  die  Entleerung  solcher  Hohlen 
eher  durch  den  Bronchialbaum,  als  durch  die  Fistel  geschieht.  Auf  Grund 
chirurgischer  Erfahrungen  muss  allerdings  der  Pneumotomie  bei  solchen 
Zustanden  eine  unmittelbare,  giinstige  Wirkung  zugesprochen  werden,  an 
die  sich  spater  leider  wieder  die  Schattenseiten  der  chronischen  Lungen- 
fistel anschliessen.  Auch  die  Pneumotomie  bei  gefahrlicher  Lungenblutung 
aus  tuberkulosen  Cavernen  (Korte)  wird  nur  aus  der  Indikation  gemacht, 
einem  dringlichen,  besonders  gefahrlichen  Zustande  durch  die  Operation 
abzuhelfen.  Ein  Einfluss  auf  den  tuberkulosen  Prozess  kommt  weder  hier 
noch  dort  in  Frage. 

Die  Erfolge  der  chirurgischen  Behandlungen  der  Lungencavernen  durch 


88  SIXTH    INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

Pneumotomie  sind  in  der  Tat  schlecht.  Bei  einer  Statistik  von  Tuffier  star- 
ben  von  26-50  %,  und  von  denen,  die  die  Operation  iiberstanden,  sind  nur 
einige  wenige,  welchen  der  Eingriff  Nutzen  gebracht  hat.  Ja  man  konnte 
im  Jahre  1897  nur  iiber  eine  einzige,  durch  die  Operation  herbeigefiihrte 
tatsachliche  Heilung  an  der  Lungencaverne  verfiigen.  Das  ist  der  Fall  von 
Sonnenburg,  den  ich  schon  oben  erwahnte. 

Auch  weitere  Falle  von  Franke,  Salomoni,  Malbet,  Sarfert,  Landerer  und 
anderen  sind  ohne  den  gewiinschten  Erfolg  operiert  worden.  Nur  ein  ein- 
ziger  lebte  langer  als  zwei  Jahre,  die  anderen  gingen  an  ihrer  Tuberkulose  zu 
Grunde  (Karewsky). 

Diese  Resultate  reden  eindringlich  gegen  die  Berechtigung  der  Pneu- 
motomie, zumal  wenn  man  bedenkt,  dass  Besserungen,  iiber  die  Operateure 
in  einzelnen  Fallen  berichten,  auch  ohne  Operation  haufig  zur  Beobachtung 
kommen.  Patienten  mit  grossen  Cavernen  konnen  jahrelang  leben,  und 
bei  ausreichender  Expectoration,  sogar  unter  relativem  Wohlbefinden  ihrem 
Berufe  nachgehen. 

Allerdings  scheint  bei  einer  besonderen  Form  der  Cavernenbildung  der 
Lunge  die  Operation  giinstigere  Resultate  zu  erzielen;  das  sind  die  Falle  in 
denen  der  tuberkulose  Zerfall  der  Lunge  die  Peripherie  derselben  erreicht, 
und  nach  fester  Verklebung  beider  Pleurablatter  auch  auf  die  Brustwand 
selbst  iibergreift. 

Ubereinstimmend  werden  hiervon  mehreren  Chirurgen  (Tuffier,  Naentjen, 
und  Karewsky)  Heilungen  berichtet.  Karewsky  empfiehlt,  die  Brustwand 
in  grosser  Ausdehnung  fortzunehmen,  und  die  tuberkulosen  Massen  durch 
Auskratzung  mit  dem  scharfen  Loffel  zu  beseitigen. 

Diese  giinstigen  Falle  sind  aber  sehr  selten. 

Die  ungiinstigen  Erfolge  der  Pneumotomie  bei  tuberkulosen  Lungen- 
cavernen  werden  von  den  meisten  Chirurgen  und  Internen  anerkannt.  Sie 
erklaren  den  gegenwJirtigen  ablehnenden  Standpunkt  gegen  diese  Operation. 
Dieser  Eingriff  hat,  wie  gesagt,  nur  bei  ganz  bestimmten  Formen  (isolierte 
Caverne  mit  Resorptionserscheinungen)  infolge  ungiinstiger  Abflussverhalt- 
nisse,  oder  bei  kleinen  peripher  gelegenen  Hohlen  mit  Ubergreifen  auf  die 
Brustwand  seine  Berechtigung.  Schon  Quincke  hat  die  Pneumotomie  bei 
tuberkulosen  Cavernen  im  Grossen  und  Ganzen  verworfen,  und  als  erster 
eine  andere  chirurgische  Behandlung  vorgeschlagen,  "die  Mobilisation  der 
Brustwand  durch  ausgedehnte  Rippenresektion."  Sein  Vorschlag  stiitzt 
sich  auf  der  Tatsache,  dass  der  Ausheilung  aller  Lungenhohlen,  besonders 
aber  der  tuberkulosen  Cavernen,  die  meist  im  oberen  Thoraxabschnitt  sitzen, 
als  Haupthindernis  die  Starre  des  umgebenden  Knochenringes  im  Wege 
steht.  Durch  ausgedehnte  Rippenresektion  hofft  er  einen  Collaps  der  Hohle 
mit  Retraction  des  Lungengewebes  und  Narbenbildung  zu  ermoglichen,  und 
auf  diese  Weise  eine  Spontanheilung  anzubahnen.     Er  empfiehlt  diese  Opera- 


LUNGENTUBERKULOSE,    CHIRURGISCHE    BEHANDLUNG. — SATJERBRUCH.      89 

tion  nur  fiir  die  fibrose  Form  der  Phthise,  betont  aber  ausdriicklich,  dass 
sie  hier  auch  in  den  Fallen  berechtigt  ist,  bei  denen  Cavernen  nicht  bestehen. 
Vorschlag  Quinckes  hat  in  aller  jiingster  Zeit  wieder  eine  besondere  Bedeu- 
tung  erlangt.     Darauf  komme  ich  noch  zuriick. 

Viel  ernstere  Beachtung,  als  alle  bisher  besprochenen  Methoden  opera- 
tiver  Behandlung  der  Lungentuberkulose  verdienen  Vorschlage,  die  in  aller 
jiingster  Zeit  gemacht  worden  sind.  Sie  stiitzen  sich  an  altere  Ideen  und 
Versuche,  aber  durch  die  besondere  Art  ihrer  Ausflihrung  werden  sie  viel- 
leicht  den  Weg  zeigen  wie  wir  der  Tuberkulose  der  Lunge  operativ  beikom- 
men  konnen.  Es  ist  die  Freund'sche  Operation  der  Tuberkulose  der  Lungen- 
spitze  und  die  Behandlung  der  vornehmlich  einseitigen  tuberkulosen  Er- 
krankungen  mit  oder  ohne  Hohlenbildungen  durch  Lungencollaps. 

Die  Operation  bei  der  Tuberkulose  der  Spitze  stiitzt  sich  im  wesentlichen 
auf  Arbeiten,  die  bereits  vor  einem  halben  Jahrhundert  Alexander  Freund 
veroffentlichte,  Freund  machte  damals  den  Vorschlag,  durch  Durchtren- 
nung  des  ersten  Bippenknorpels  eine  Besserung  oder  Heilung  bei  Spitzen- 
tuberkulose  herbeizufiihren.  Dieser  Vorschlag  war  die  Folge  seiner  Unter- 
suchungen  liber  die  Verengerungen  der  oberen  Brustapertur  und  ihres  Ein- 
flusses  auf  die  Entwickelung  der  Tuberkulose.  Es  stellte  sich  heraus,  dass 
in  sehr  vielen  Fallen  eine  Verkiirzung  der  ersten  Rippenknorpel  bezw.  der 
ersten  Rippe  selbst  beobachtet  wird,  und  dass  infolge  dieser  Verkiirzung  bei 
der,  durch  die  beiden  ersten  Rippen  gelegten  Ebene  eine  verstarkte 
Neigung  gegen  die  Horizontale  eintreten  kann.  Diese  Entwickelungshem- 
mung  wird  meist  erst  im  Pubertatsalter  von  Bedeutung,  und  zwar  dadurch, 
dass  die  Lungenspitze  infolge  des  verengten  Raumes  durch  die  erste  Rippe 
komprimiert  wird  und  die  zufiihrenden  Bronchien  vereng-t  werden.  Als 
weitere,  interessante  Tatsache  konnte  dann  Freund  nachweisen,  dass  der- 
artige  Rippen  auch  viel  friiher  verknochern,  damit  ihre  Elastizitat  verlieren, 
und  als  unbewegliche  Spangen  sich  an  der  Liiftung  des  Thorax  nicht  mehr 
beteiligen.  Eine  wertvolle  Ergiinzung  zu  diesen  Freund'schen  Beobachtun- 
gen  lieferte  dann  Hart  in  seiner  Monographie  iiber  "die  mechanische  Dispo- 
sition der  Lungenspitzen  zur  tuberkulosen  Phthise."  Auch  er  konnte 
zunachst  die  Beobachtungen  Freunds  bestiitigen,  dass  die,  durch  eine  in  der 
Kindheit  durchgemachte  Entwickelungshemmung  verkiirzten  Rippen- 
knorpel die  normale  quer-ovale  Kartenherzform  der  oberen  Brustoffnung  in 
eine  engere,  grad-ovale  Form  umwandeln.  Ferner  stellte  er  fest,  dass  diese 
Rippen  eine  grosse  Neigimg  zur  Verknocherung  habcn.  Ausserdem  aber 
fand  er,  dass  dieselbe  vorzeitige  Verknocherung,  und  zwar  ohne  Veriinderung 
der  Form  der  Offnung,  auch  bei  der  Lungenspitzentuberkulose  auftritt. 
In  diesen  Fallen  hat  der  obere  Rippenring  nur  seine  Beweglichkeit  und  seine 
Beteiligimg  an  der  Thoraxbewegung  verlorcn.  Weiter  liess  sich  feststellen, 
dass  bei  ausgeheilter  Lungenspitzentuberkulose,  sich  ofters  an  dem  ver- 


90  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

knocherten  Rippenknorpel,  an  der  Knorpelknochengrenze,  ein  neugebildetes 
Gelenk  findet.  Diese  gewiss  sehr  wichtigen,  anatomischen  Befunde  lassen 
sich  in  Einklang  bringen  mit  anderen  bemerkenswerten  Beobachtungen  der 
pathologischen  Anatomen.  So  zeigte  Birch-Hirschfeld,  dass  die  Lungen- 
tiiberkulose  meist  in  den  Bronchien  3.  bis  5.  Ordnung  des  Oberlappens 
beginnt,  und  besonders  haufig  in  dem  spitzen  Ast,den  er  als  Bronchus  apicis 
posterior  bezeichnet.  Er  nahm  an,  dass  die  steile  Verlaufsrichtung  dieser 
Bronchien  es  mit  sich  bringt,  dass  der  Luftstrom  bei  der  Atmung,  dem  in  der 
Luftrohre  entgegengesetzt  ist,  und  glaubt,  dass  dadurch  leichter  infectioses 
Material  bei  der  Atmung  dort  sich  ansammeln  kann.  Wichtiger  ist,  dass  er 
durch  Ausgiisse  des  Bronchialbaums  sehr  haufig  Kompression  und  Formver- 
anderungen  an  diesen  Bronchialasten  nachweisen  konnte,  die  seiner  Ansicht 
nach  ein  Beweis  dafiir  seien,  dass  raumbeengende  Momente  auf  dieselben 
gedriickt  haben.  Die  beste  Unterlage  fiir  diese  VorsteUung  der  mechani- 
schen  Kompression  der  Lunge  durch  die  erste  Rippe  lieferte  dann  Schmerl. 
Dieser  Autor  beschrieb  niimlich  eine,  an  Lungen  Erwachsener  vorkommende, 
"  die  Lungenspitze  von  hinten  und  oben  nach  vorn  und  unten  zu  umgreifende 
Furche.  Diese  Furche  ist  in  einzelnen  Fallen  verschieden  stark  entwickelt; 
bald  erscheint  sie  als  fiache  Rinne,  die  oben  nur  angedeutet  ist,  bald  als  1  cm. 
breite,  scharf  von  der  Umgebung  abgesetzte,  bis  fingerdicke  Einsenkung, 
durch  welche  eine  Abschniirung  der  Lungenspitze  von  den  iibrigen  Lungen- 
abschnitten  des  Lungengewebes  am  stiirksten  entwickelt  und  am  tiefsten. 
Sie  liegt  1  bis  2  cm.  unterhalb  der  hochsten  Erhebung  der  Lungenspitze, 
also  gerade  in  dem  Verbreitungsbezirke  derjenigen  Bronchialaste,  welche 
nach  Birch-Hirsclifeld  einerseits  am  haufigsten  Irregularitiiten  ihres  Verlaufs 
und  ihrer  Anordnung  erkennen  lassen;  andererseits  aber  die  Predilektions- 
stelle  fiir  die  beginnende  Tuberkulose  bilden."  Auch  Schmerl  erklart  diese 
Furchenbildung  durch  mangelhafte  Entwickelung  der  ersten  Rippe,  Ver- 
engerung  der  Brustapertur  und  Druck  auf  die  Lungenspitze. 

Umsomehr  erscheint  diese  tJberlegung  berechtigt,  als,  wie  gesagt,  in 
vielen  Fallen  ausgeheilter  Spitzentuberkulose,  Gelenkbildung  an  der  Knor- 
pelknochengrenze der  verkiirzten  Rippe  gefunden  wird.  Hart  stellte  sogar 
in  400  Leichen  Erwachsener,  in  97  Fallen,  Gelenkbildung  an  dem  ersten 
Rippenknorpel  fest.  In  den  45  Fallen  einseitiger  Gelenkbildung  fand  sich 
30  mal  ganz,  oder  nahezu  ganz,  abgeheilte  Tuberkulose;  9  mal  waren  die 
Spitzen  gesund,  6  mal  lag  proretente  Phthise  vor;  unter  52  Fallen  doppel- 
seitiger  Gelenkbildung  fand  sich  33  mal  ausgeheilte  oder  in  Heilung  be- 
griffene  Tuberkulose;  2  mal  progrediente  Phthise,  8  mal  waren  die  Lungen- 
spitzen  gesund.  Unter  97  Fallen  von  Gelenkbildung  fand  sich  also  63  mal 
Ausheilung  eines  tuberkulosen  Spitzenprozesses;  17  mal  zeigten  die  Lungen 
keine  Spuren  vorhergegangener  Erkrankung,  und  17  mal  lag  progrediente 
Phthise  vor. 


LUNGENTUBERKULOSE,    CHIRURGISCHE   BEHANDLUNG. — SAUERBRUCH.      91 

Der  erste,  der  auf  Grund  dieser  zwingenden  Uberlegungen  in  einem  ge- 
eigneten  Falle  von  Spitzentuberkulose  die  ^Mobilisation  der  ersten  Rippe 
vornahm,  war  Kausch.  Am  6  2  1907  resezierte  er  bei  einer  53jahrigen 
Frau  1-15  cm.  der  ersten  rechten  Rippe  an  der  Knorpelknochengrenze. 
Bei  der  Operation  fand  er  den  Knorpel  verdickt  imd  stark  verknochert. 
Noch  wahrend  der  Operation  konnte  er  beobachten,  wie  die  erste  Rippe 
langsam  begann,  sich  an  der  Atmung  zu  beteiligen.  Der  Verlauf  war  glatt, 
nur  traten  bald  nach  der  Operation  reissende  Schmerzen  im  rechten  Arm  auf, 
die  auf  eine  Reizung  des  Rippenstumpfes  auf  den  plexus  brachialis  zu  be- 
ziehen  sind.  Wichtig  ist,  dass  bereits  nach  3  Wochen  der  Lungenbefund 
sich  wesentlich  gebessert  hatte. 

Bald  darauf  operierte  dann  Seidel  2  weitere  Falle.  In  dem  ersten  Falle 
handelte  es  sich  um  einen  21jahrigen  j\Iann  mit  linksseitigem,  ausgesproche- 
nem  Spitzenkatarrh  und  typisch  paralytischem  Thorax.  Seidel  resezierte 
2  cm.  des  Knorpels  der  1.  Rippe.  Auch  bei  diesem  Patienten  traten  in  der 
ersten  Zeit  ziehende  Schmerzen  im  linken  Arme  auf,  die  dann  aber  von  selbst 
verschwanden.  Der  Patient  wurde  nach  der  Operation  einer  Lungenheil- 
statte  iiberwdesen  und  als  geheilt  entlassen. 

In  dem  zweiten  Falle  wurde  ein  20jahriger  Pfleger  wegen  rechtssei tiger 
Spitzentuberkulose  in  derselben  Weise  operiert.  Auch  Seidel  konnte  hier 
beobachten,  dass  noch  wahrend  der  Operation  die  erste  Rippe  die  Atmung 
wieder  aufnehmen. 

Die  Beurteilung  iiber  den  Wert  dieser  neuen  Behandlungsmethode  der 
Spitzentuberkulose  ist  schwierig.  Die  Beobachtungszeit  nach  der  Operation 
ist  noch  zu  kurz,  und  die  Zahl  der  Fiille  zu  gering.  Der  unmittelbare  Erfolg 
aller  Falle  und  die  Einfachheit  der  Ausfiihrung  der  Operation  ermutigen  zu 
weiteren  Versuchen  auf  diesem  Wege,  und  es  ware  zu  hoffen,  dass  diese  auf 
exacter  pathologisch-anatomischer  Beobachtung  die  Griinde  der  Therapie 
behanptete. 

Aber  ahnlich,  wie  bei  der  Resektion  der  Lungenspitze  ist  hier  die  Frage 
berechtigt,  ob  die  Operation  notwendig  ist.  Die  vielen  Spontanheilungen 
der  beginnenden,  friihzeitig  behandelten  Spitzentuberkulosen  lassen  es  auch 
hier  zwcifelhaft  erscheinen.  Allerdings  hat  die  Freund'sche  Operation 
gegeniiber  der  Spitzenresektion  den  grossen  Vorteil  der  relativen  Gefahr- 
losigkeit  und  Einfachheit  der  Ausfiihrung.  Deshalb  konnte  man  eher  ge- 
neigt  sein,  in  geeigneten  Fallen  Versuche  mit  ihr  zu  machen.  ^lan  miisste 
sie  dann  ansehen  als  ein  Unterstiitzungsmittcl  bei  der  Therapie  der  Lungen- 
tuberkulose.  j\Ichr  vnrd  nicht  zu  erwarten  sein.  Denn  die  Operation 
erreicht  keine  Beseitigung  des  tuberkulosen  Herdes,  der  die  Resektion  der 
Spitze  anstrebt,  sondern  sie  schafft  nur  giinstigere  Verhiiltnisse  fiir  den 
Heilungsprozess.  Daraus  folgt  also,  dass  wir,  trotz  der  jMobilisation  der 
ersten  Rippe  immer  nach  wie  vor,  die  Allgemeinbehandlung  einleiten  miissen. 


92  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

Auch  ist  noch  nicht  sicher  erwiesen,  dass  der  tuberkulose  Prozess  in  der 
arbeitenden,  sich  bewegenden  Spitze  besser  ausheilt  als  in  der  ruhenden. 
Unsern  Erfahrungen  bei  der  Tuberkulose  anderer  Organe  widerspricht  er. 
Das  tuberkulose  Kniegelenk  heilt,  wenn  es  ruhig  gestellt  wird,  und  die  tuber- 
kulose Hiifte  wird  in  Streck-  und  Gipsverbande  gelegt,  damit  jede  Bewegung 
und  Funlction  ausgeschaltet  wird.  Auch  an  der  Lunge  selbst  scheint  die 
absolute  Ruhigstellung  doch  von  Bedeutung  zu  sein,  wie  uns  die  Erf ahrungen 
mit  der  Pneumothoraxbehandlung  lehren.  Auf  der  anderen  Seite  konnen 
wir  dagegen  annehmen,  dass  gerade  die  bessere  Durchflutung  der  Spitze  mit 
Blut  fiir  die  Ausheilung  eines  tuberkulosen  Prozesses  gimstiger  ware.  Die 
Richtigkeit  dieser  Auffassung  zugegeben,  muss  man  anerkennen,  dass  wir 
eine  Hebung  der  Cirkulation  auch  auf  anderem  Wege,  durch  Atmungsgym- 
nastik  und  durch  Atmung  im  pneumatischen  Kabinett,  einfacher  erreichen 
konnen.  Besondere  Erwahnung  verdient  die  Anwendung  der  Kuhn'schen 
Lungensaugmaske.  Ihre  Wirkung  besteht  darin,  dass  die  Inspiration  be- 
trachtlich  erschwert  wird,  und  auf  diese  Weise  eine  Dehnung  der  Lungen- 
alveolen  erzielt  wird.  Gleichzeitig  entsteht  dadurch  die  Hyperamie  der 
Alveolargefasse.  Es  liegen  bereits  eine  ganze  Reihe  giinstiger  Berichte 
vor,  die  zu  weiteren  Versuchen  mit  dieser  Methode  durchaus  ermutigen. 
Auch  anatomische  und  physiologische  Bedenken  gegen  die  Freund'sche 
Lehre  fehlen  nicht.  So  liesse  sich  bei  der  grossen  Abhangigkeit  des  Skelettes 
von  den  Weichteilen  die  Freund'sche  Verknocherung  der  ersten  Rippe  in 
einzelnen  Fallen  (natiirlich  nicht  da,  wo  dieselbe  bereits  in  der  Jugend  auf- 
trat)  sehr  wohl  als  eine  Folge,  und  nicht  als  die  Ursache,  einer  mangelhaften 
Tatigkeit  des  oberen  Thoraxabschnittes  ansehen. 

Auch  die  Bedeutung  der  Schmerl'schen  Lungenfurche  darf  nicht  iiber- 
schatzt  werden,  denn  eine  andere  Eindallung  der  Spitze  wird  fast  bei  alien 
Menschen  auf  der  Vorderseite  beobachtet.  Es  ist  die,  die  nach  Pansch  durch 
den  Druck  der  Subclavia  entstanden  ist.  Beachtenswert  sind  schliessHch 
auch  die  Einwande,  die  Hofl^auer  gegen  die  Freund'sche  Theorie  anfiihrt. 
Er  glaubt  auf  Grund  exacter  physiologischer  IMessungen,  dass  die  Excursions- 
fahigkeit  des  oberen  Thoraxabschnittes  geniigend  ist,  und  dass  eine  regel- 
massig  durchgefiihrte  Atmungsgymnastik  eine  Besserung  der  Spitzenatmung 
herbeiftihren  kann  ohne  Operation.  Auf  Einzelheiten  dieser  interessanten 
Arbeit  kann  nicht  naher  eingegangen  werden.  Immerhin  scheint  aber  die 
Freund'sche  Operation  fiir  einzelne  ausgesuchte  Falle,  bei  denen  eine  wirk- 
liche,  funktionell  nachweisbare  Starrheit  der  ersten  Rippe  besteht,  durchaus 
angezeigt,  und  weitere  Arbeit  auf  diesem  Wege  ist  nicht  aussichtslos. 

Ein  endgiiltiges  Urteil  iiber  den  Wert  der  operativen  Mobilisation  der 
Spitze  lasst  sich  heute  noch  nicht  fallen.  Schon  Kausch  betont,  "dass  nur 
zahlreiche  Falle,  lange  Beobachtungsdauer,  und  strenge  Kritik  zu  einem 
definitiven  Urteil  fiihren  konnen." 


LUNGENTUBERKULOSE,    CHIRURGISCHE    BEHANDLUNG. — SAUERBRUCH.      93 

Die  neueste  Wendung  in  der  Chirurgie  der  Lungentuberkulose  wird 
dargestellt  durch  die  Versuche,  einseitige  Phthisen  durch  kiinstlichen  Lungen- 
collaps  zu  behandeln.  Derselbe  wird  erreicht  entweder  durch  Anlegen 
eines  kiinstlichen  Pneumothorax,  oder  durch  MobiUsation  der  ganzen  Brust- 
wand  durch  totale  "  Entknochung  "  derselben. 

Forlanini  war  der  erste,  der  den  Pneumothorax  bei  der  Behandlung  der 
Lungentuberkulose  empfahl.  Unabhangig  von  ihm  kam  Murphy  auf  die- 
selbe  Idee.  Neuerdings  hat  Brauer  dieses  Verfahren  ganz  besonders  aus- 
gearbeitet.  Es  besteht  darin,  dass  den  Patienten  durch  Einblasen  eines 
bestimmten  Quantums  Stickstoff  (durchschnittlich  500-1000  cm.)  ein 
kiinsthcher  Pneumothorax  angelegt,  und  auf  diese  Weise  die  Lunge  zum 
CoUaps  gebracht  wird.  Die  durch  die  Lungenkompression  hervorgerufene 
funktionelle  Ausschaltung  der  Lunge,  ihre  Ruhigstellung,  ferner  die  Veran- 
derungen  in  der  Blut-  und  Lymphcirculation,  sollen  die  Bindegewebswuch- 
erungen  begiinstigen,  und  dadurch  eine  Heilung  der  Tuberkulose  ermoglichen. 
Die  urspriingliche  Technik  dieses  Verfahrens  war  so,  dass  in  der  iibhchen 
Weise  die  Pleurahohle  punktiert  wurde,  und  durch  die  Punktionskanale 
unter  Controlle  der  ]\Ienge  und  des  Druckes  Stickstoff  eingelassen  wurde. 
Stickstoff  wurde  genommen,  well  er  schlechter  als  andere  Gase  resorbiert 
wird,  und  der  Pneumothorax  damit  langere  Zeit  besteht.  Murphy  und 
Brauer  haben  diese  Technik  abgeandert.  Speciell  Brauer  ist  der  Ansicht, 
dass  in  dem  infiltrierten  Lungengewebe  die  diinnwandigen  Lungenvenen  der 
Punktionsnadel  nicht,  wie  im  gesunden  Gewebe,  ausweichen  konnen,  und 
ihre  Verletzung  gelegentlich  zu  tothcher  Luftembolie  fiihrt.  Auch  kann  bei 
einer  solchen  Punktion  sehr  leicht  ein  grosserer,  tuberkuloser  Herd  der 
Lunge  getroffen  werden,  dessen  Eroffnung  dann  sekundar  zu  einer  Infektion 
der  Pleurahohle  fiihrt.  Vor  alien  Dingen  aber  ist  es  bei  der  einfachen 
Punktion  unmoglich,  sich  von  der  Beschaffenheit  der  Pleurablatter  zu  iiber- 
zeugen.  Voraussetzung  fiir  das  Gelingen  eines  Pneumothorax  ist  namlich 
das  Fehlen  ausgedehnter  Pleuraverwachsungen.  Brauer  hat  aus  diesem 
Grunde  der  Punktion  der  Pleuraholile  eine  Incision  in  einem  Intercostalraum 
vorausgeschickt.  Er  durchtrennt  mit  einem  5  cm.  langen  Schnitt  die 
Muskulatur  bis  auf  die  Pleura.  Jetzt  wird  mit  einem  stumpfen  Troikar  die 
Pleurahohle  eroffnet.  Es  dringt  Luft  neben  dem  Instrument  in  dieselbe 
ein,  die  Lunge  collabiert,  weicht  der  Punktionsnadel  aus,  und  wird  auf  diese 
Weise  nicht  verletzt.  Erst  jetzt  wird  in  derselben  Weise  wie  bei  der  ein- 
fachen Punktion  ein  bestimmtes  Quantum  Stickstoff  in  die  Pleurahohle 
eingelassen,  und  dann  die  Weichteilwunde  durch  einige  Nahte  wieder  ge- 
schlossen.  Es  ist  dabei  Wert  auf  eine  exakte  Muskelnaht  zu  legen,  um  das 
Zustandekommen  eines  Ilautcmphysems  zu  vermciden.  Ein  derartiger 
Schnitt  bedeutet  keine  Komplication  der  Operation,  verhindert  aber  Gefahren 
und  lasst  von  vornherein  erkennen,  ob  iiberhaupt  die  Pneumothoraxtherapie 


94  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

durchfiihrbar  ist,  oder  nicht.  Sowohl  bei  der  Punktion  als  auch  bei  der 
Schnittmethode  muss  der  zuerst  angelegte  Pneumothorax  in  bestimmten 
Zeitintervallen  erneuert  werden.  Diese  sogenannte  Nachfiillung  des  Pneu- 
mothorax kann  nun  in  der  gewohnhchen  Weise,  durch  einfache  Punktion 
vorgenommen  werden.  Unter  Controlle  des  Rontgenschirms  und  unter 
Beobachtungen  des  Manometers  wird  die  Pneumothoraxblase  eingestellt, 
und  jetzt  die  Nadel  in  den  Hohlraum  eingestochen.  Die  Operation  ist,  wie 
ich  mich  selbst  iiberzeugen  konnte,  einfach,  und  wenn  keine  Pleuraverwacli- 
sungen  da  sind,  zuverlassig.  Es  lassen  sich  in  einer  Sitzung  500,  800,  ja 
1000  cm.  Stickstoff  einfiillen,  ohne  dass  Storungen  der  Atmung  oder  der 
Herztatigkeit  eintreten.  Die  Punktion  selbst  kann  jnit  lokaler  Anasthesie 
vorgenommen  werden. 

Brauer  berichtet  iiber  60  Patienten,  bei  denen  er  diese  Pneumothorax- 
therapie  angewendet  hat.  In  45  von  diesen  Fallen,  also  in  75  %,  fand  sich 
freier  Pleuraraum,  so  dass  die  Anlegung  des  Pneumothorax  gelang.  Auf 
Grund  dieses  Materials  berichtet  Brauer  iiber  Indication  und  Erfolg  dieser 
Behandlungsmethode.  Das  Verfahren  ist  angezeigt  bei  alien,  in  der  Haupt- 
sache  einseitigen  Phthisen,  mit  und  ohne  Hohlenbildung,  die  bisher  den 
allgemeinen  Behandlungsmethoden  getrotzt  hatten.  Voraussetzung  ist  aber, 
dass  keine  Verwachsungen  der  Pleurahohle  bestehen,  denn  diese  verhindern 
das  Zustandekommen  eines  kiinstlichen  Pneumothorax,  und  sind  fiir  diese 
Therapie  voUstandig  ungeeignet.  Bei  diesen  Patienten  kann  die  Retraction 
der  Lunge  fiir  narbige  Schrumpfung  nur  durch  ]\Iobilisation  der  Brustwand, 
d.  h.  Abtragung  aller  Rippen  erzielt  werden. 

Die  sicherste  und  haufigste  Wirkung  des  Pneumothorax  zeigt  sich  in  dem 
Abfall  des  Fiebers.  Das  Fieber  verschwindet  in  solchen  P'allen  verschieden 
rasch,  bleibt  dann  entweder  dauernd  fort,  oder  tritt  nur  gelegentlich  wieder 
in  der  Form  sporadischer  Temperatursteigerung  auf.  Auch  das  Korperge- 
wicht  pflegt  bei  gesunden  Verdauungsorganen  bald  zu  steigen,  die  Sputum- 
menge  nimmt  ab,  es  sinken  bezw.  verschwinden  die  elastischen  Fasern  und 
Tuberkelbazillen,  und  mehrfach  blieb  das  Sputum  iiberhaupt  ganz  aus. 
Auch  konnte  Brauer  mehrfach  beobachten,  dass  nach  Einleitung  der  Pneu- 
mothoraxbehandlung  erregte  Herzalction,  massige  Cyanose  und  dyspnoische 
Atmung  verschwanden.  Schliesslich  erwahnt  Brauer  als  weiteren  Erfolg 
die  gute  Riickwirkung  auf  das  subjektive  Befinden.  Die  Leute  fiihlen  sich 
wohler  und  werden  leistungsfahiger.  Gelegentlich  beobachtete  Brauer  im 
weiteren  Verlauf  serose  Exudationen  in  die  Pleurahohle,  die  im  allgemeinen 
ohne  weitere  Bedeutung  fiir  die  Patienten  waren.  Sie  sind  wohl  als  Folgen 
der  Reizung  durch  die  starke  Stickstoff-Fiillung  anzusehen. 

Weit  wichtiger  als  die  klinischen  Beobachtungen  scheinen  mir  die 
pathologisch-anatomischen  Unterlagen  zu  sein,  die  Brauer  fiir  die  Pneumo- 
thoraxtherapie  beibringen  kann.     Von  7  Fallen,  die  im  Laufe  der  Behandlung 


LUNGENTUBERKULOSE,    CHIRURGISCHE   BEHANDLUNG. — SAUERBRUCH.      95 

starben,  wiirden  3  seziert.  Es  fanden  sich  in  der  Collapslunge  nur  vereinzelt 
frische  Tuberkel,  in  den  Tuberkeln  auffallend  trockene  Verkasungen.  Aus- 
serdem  wenig  acute  Zerfallserscheinungen;  dagegen  sehr  ausgepragte, 
reactive  Bindegewebsvermehrung  und  vorgeschrittene  Narbenbildung. 
Diese  Befunde  sind  zum  mindesten  ein  Beweis  dafiir,  dass  die  pathologisch- 
anatomischen  Voraussetzungen  des  Verfahrens  richtige  sein  konnen.  Die 
Tuberkulose  heilt  erfahrungsgemass  durch  Bindegewebswucherungen  aus, 
der  kiinstliche  Pneumothorax  regt  eine  derartige  Bindegewebswucherung  an, 
folglich  ist  der  Pneumothoraxtherapie  eine  Heilwirkung  bei  der  Tuberkulose 
zuzusprechen.  Ein  Hauptvorteil  des  Verfahrens  liegt  meines  Erachtens 
darin,  dass  es  mit  einfachen  Mitteln,  ohne  eingreifende  Operation  erzielt 
werden  kann.  Die  Gefahr  der  Lungenverletzung  lasst  sich  durch  das 
Brauer'sche  Vorgehen  vermeiden,  wohl  das  einzige  Bedenken,  das  man 
gegen  das  Verfahren  haben  kann.  Unangenehm  fiir  den  Patienten  ist  nur 
das  haufige  Nachfiillen. 

Nach  Brauers  Indicationsstellung  kommt  die  Pneumothoraxbehandlung 
nur  bei  fortgeschritteneren  Fallen  zur  Anwendung.  Sie  hat  zur  unbedingten 
Voraussetzung  eine  freie  Pleurahohle,  in  der  sich  ein  Pneumothorax  zuver- 
lassig  anlegen  lasst.  Die  Erfolge  Brauers  und  Forlaninis  sprechen  dafiir, 
dass  das  Verfahren  mehr  als  bisher  angewendet  werden  sollte. 

Die  zweite  Form  der  Behandlung  chronischer  Phthisen  durch  Lungen- 
coUaps  und  Kompression,  oder  durch  "  Volumeneinengung"  der  Lunge,  ist 
eine  Erweiterung  der  von  Quincke  und  Spengler  angeregten,  und  von  Speng- 
ler,  Bier,  Landerer,  Turban,  und  v.  Mikulicz  bereits  ausgefiihrten  Mobilisa- 
tion der  Brustwand.  Diese  Operation  sollte  zuerst  nur  dem  Zwecke  dienen, 
umschriebene  Brustwandpartien  iiber  Cavernen  im  Lungengewebe  durch 
Rippenresektion  nachgiebig  zu  machen,  und  dadurch  die  Hohle  zum  Collaps 
zu  bringen.  Aber  Quincke  hat  seine  Idee  der  kiinstlichen  Narbenschrump- 
fung  der  Lunge  auch  schon  ausgedehnt  auf  Falle  ohne  Cavernenbildung,  bei 
denen  es  sich  um  eine  universelle,  einseitige  Phthise  handelte. 

Wahrend  die  friiheren  Operateure  aber  die  Pippen  nur  in  einer  Ausdeh- 
nung  von  30-50  cm.  wegnahmen,  entfernt  Friedrich,  der  diese  Mobilisation 
der  Brustwand  neuerdings  in  besonderer  Weise  vornimmt,  im  Durchschnitt 
ungefahr  200  cm. 

Zunachst  wurde  diese  erweiterte  Methode  angewandt  bei  4  Patienten, 
bei  denen  Brauer  die  Aniegung  des  kiinstlichen  Pneumothorax  wegen 
Verwachsungen  der  Pleurablatter  nicht  gelungen  war.  Fiir  derartige  Fiille 
hatte  Brauer  bereits  in  seiner  ausfiihrlichen  Pneumothoraxarl^eit  im  Uni- 
versitatsprogramm  1906  die  Quincke-Spengler'sche  Operation  in  Aus- 
sicht  genommen.  Im  Einverstiindnis  mit  Brauer  hat  dann  Friedrich  diese 
Mobilisation  der  Brustwand  durch  ausgedehnte  Rippenresektion  vorge- 
nommen.     Die  technische  Ausfiihrung  dieser  Operation  wurde  von  Fried- 


96  SIXTH    INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

rich  aber  so  erweitert  unci  geandert,  class  dieselbe  in  der  jetzigen  Form  als 
"Entknochimg  des  Thorax"  ganz  erheblich  von  dem  urspriinglichen  Vor- 
gehen  Quincke-Spengler's  abweicht.  Friedrich  begniigt  sich  nicht  mehr  mit 
der  Resektion  einiger  Rippen,  sondern  nimmt  in  grosser  Ausdehnung  vom 
Sternalrand  bis  zum  Angiilus  costse  die  2.-10.  Rippe,  mit  peinlichster  Scho- 
nung  der  Pleura  fort.  Die  Weichteilschnittfiihrung  bei  dieser  Operation  ist 
dieselbe,  wie  bei  der  Scheede'schen  Thorakoplastik:  nach  Bildung  eines 
Hautmuskellappens  dergestalt,  dass  die  letzten  Zacken  des  Musculus  serratus 
stehen  bleiben,  wahrend  der  ganze  iibrige  Muskel  mit  seinen  Nerven  und 
Gefassen  im  raschen  Zuge  nach  oben  geklappt  wird,  unter  gleichzeitiger 
rechtwinkliger  Abhebelung  des  Schulterblattes  vom  Thorax.  Hierdurch 
wird  innerhalb  weniger  Minuten  die  freieste  Ubersicht  liber  die  2.-10.  Rippe 
gewonnen.  Der  2.  Akt  besteht  dann  in  der  Wegnahme  der  Rippen  unter 
sorgfaltiger  Schonung  der  Pleura.  Dies  gelingt  dort,  wo  sie  durch  alte 
Entziindung  oder  Verwachsung  mit  der  Lunge  verdickt  ist,  leicht;  allerdings 
muss  hei-vorgehoben  werden,  dass  die  Starke  der  Pleura  selbst  bei  demselben 
Kranken  an  verschiedenen  Stellen  wechseln  kann;  sodass  immer  grosste 
Vorsicht  bei  der  Auslosung  der  Rippen  geboten  ist.  Wo  Verwachsungen 
fehlen,  kann  selbst  dem  Geiibtesten  gelegentlich  ein  Einriss  des  Brustfells 
vorkommen.  An  sich  hat  diese  Complication  immerhin  nicht  die  Be- 
deutung,  wie  einige,  so  zum  Beispiel  Turban,  annehmen,  zumal  dann,  wenn 
die  augenblicklichen  Gefahren  des  Pneumothorax  durch  Tamponade,  oder 
besser  durch  Anwendung  von  Druckdifferenz  vermieden  werden,  und  wenn 
der  Schluss  der  Pleurawunde  sofort  so  gelingt,  dass  eine  sekundare  Infection 
der  Brusthohle  verhindert  wird. 

Friedrich  hat  im  ganzen  7  Falle  in  dieser  Weise  operiert.  Es  handelte 
sich  immer  um  in  der  Hauptsache  einseitige  Phthisen,  bei  denen  die  bisherige 
Behandlung  keine,  oder  nur  geringe,  Besserung  erzielt  hatte.  Von  diesen  7 
Patienten  starben  2  kurze  Zeit  nach  der  Operation;  2  von  den  tjberlebenden 
zeigten  eine  ausgezeichnete  Besserung  des  localen  und  Allgemeinzustandes, 
und  konnten  ohne  Fieber,  mit  nur  geringem  Auswurf  die  Klinik  verlassen. 
Bei  den  iibrigen  Patienten  war  die  Besserung  nicht  so  eclatant,  aber  immerhin 
doch  deutlich  nachweisbar. 

Auch  tiber  diese  Behandlungsmethode  kann  ein  endgiiltiges  Urteil  noch 
nicht  gefallt  werden.  Die  Zahl  der  Falle  ist  zu  klein,  und  die  Zeit  nach  der 
Operation  noch  zu  kurz. 

Soviel  lasst  sich  heute  aber  schon  sicher  sagen,  Fieber  und  Auswurf  wer- 
den auch  durch  die  Operation  sehr  giinstig  beeinflusst,  und  die  dadurch 
erzielte  Besserung  des  Allgemeinbefindens  kann  in  nicht  zu  weit  vorge- 
schrittenen  Fallen  eine  ganz  ausserordentliche  sein.  Die  Operation  ist 
technisch  einfach,  und  wir  wissen  aus  der  Erfahrung  bei  der  Thorakoplastik 
alter  Empyeme,  der  diese  Operation  ja  sehr  iihnelt,  wie  gut  der  grosse  Ein- 


LUNGENTUBERKULOSE,    CHIRURGISCHE   BEHANDLUNG. — SAUERBRUCH.      97 

griff,  trotz  Narcose  und  Blutverlust,  im  Allgemeinen  vertragen  wird.  So 
nahm  Scheede  bei  veralteten  Empyemen  alle  Rippen  von  der  1.  bis  zur  10., 
vom  Rippenknorpel  bis  zum  Angulus  costae  fort,  und  die  vielen  Arbeiten,  die 
die  Zweckmassigkeit  der  Scheede'schen  Operation  zum  Inhalt  haben,  berich- 
ten  iiber  ihre  relative  Gefahrlosigkeit,  trotzdem  sie  sogar  sehr  oft  bei  tuber- 
kulosen  Indi\'iduen  ausgefiihrt  wird.  Bardenheuer  hat  sogar  ausser  den 
Rippen  noch  die  Scapula  mitentfernt.  Auch  Friedrich's  Patienten  zeigen, 
dass  dieser  Eingriff  im  Grossen  und  Ganzen,  trotz  seiner  Grosse  sehr  gut 
vertragen  ^vird,  jedenfalls  von  Leuten,  deren  allgemeiner  Kraftezustand  noch 
nicht  zu  reduciert  ist. 

Aber  eine  Gefahr  hat  diese  Operation  gegeniiber  der  Scheede'schen.  Sie 
ergibt  sich  aus  der  Art  des  Eingidffes.  Nach  Entfernung  der  knochernen 
Thoraxwand  driickt  der  aussere  Luftdruck  auf  den  Weichteillappen,  und  da 
dieser  der  Lungenoberflache  aufliegt,  auch  natiirlich  auf  Lungenwurzel, 
Mediastinum,  und  vor  alien  Dingen  auf  das  Herz.  Die  Folge  davon  ist,  dass 
dieses  ahnlich  so  verdrangt  wird,  wie  es  beim  offenen  Pneumothorax  ge- 
schieht.  Wir  wissen,  dass  dieses  Verdrangen  des  Mediastinums  und  des 
Herzens  mit  seinen  Gefassen,  Hauptgrund  abgibt  fiir  die  Entstehung  der 
Pneumothoraxfolgen  (Garr6).  Die  Verlagerung  des  Herzens,  die  Compres- 
sion der  Lunge  der  andern  Seite,  das  sind  Gefahren,  die  sich  unmittelbar  an 
die  Operation  anschliessen  und  einige  Tage  fortbestehen  konnen,  bis  eine 
Anpassung  an  die  neuen  Verhaltnisse  eingetreten  ist.  Auch  im  Tierexperi- 
ment  kann  man  beobachten,  welche  Bedeutung  die  unmittelbare  Wirkung 
des  Atmospharendruckes  auf  das  Herz  hat.  Wenn  man  auf  einer  Thorax- 
seite  die  Rippen  entfernt  und  luftdicht  den  Weichteillappen  auf  die  unver- 
"  sehrte  Lunge  legt,  so  tritt,  solange  die  Tiere  unter  Druckdifferenz  bleiben, 
keine  Dyspnoe  ein.  Im  Augenblick  aber,  wo  der  aussere  Luftdruck  die 
entknocherte  Brustwand  eindriickt  und  Lunge  und  Mediastinum  belastet, 
tritt  Atemnot  bei  den  Tieren  auf.  Um  so  bemerkenswerter  ist  diese  Tat- 
sache,  als  die  Entfernung  selbst  einer  ganzen  Lunge  eine  Atmungsinsufficienz 
nicht  hervorruft.  Dass  bei  der  Scheede'schen  Operation  diese  Complication 
keine  Pi,olle  spielt,  hat  zwie  Griinde.  Erstens  besteht  ja  bei  den  betreffenden 
Patienten  seit  langer  Zeit  ein  Pneumothorax,  durch  den  allmahlich  diese 
Verdrangung  des  Mediastinums  und  die  Compression  der  andern  Lunge  schon 
eingeleitet  war,  und  nicht  plotzlich  eintritt.  Zweitens  kann  das  narbige, 
derbe  Mediastinum  bei  einem  chronischen  Empyem  nicht  mit  dem  normalen 
Mittelfell  verglichen  werden;  ersteres  ist  eine  feste,  unnachgiebige  Scheide- 
wand,  letzteres  eine  diinne,  nachgiebige,  flatternde  Haut. 

Im  Einklange  mit  diesen  Tatsachen  steht,  dass  nach  den  ausgedehnten 
Rippenresektionen  oft  eine  voriibergehende,  kritische  Hcrzschwache  eintritt. 
Es  wird  in  einigen  Fallen  das  Pendeln  des  Herzens  und  die  ihm  zugernutete 
Mehrarbeit  zu  einer  ernsteren  Schadigung  fiihren   konnen,   und  dadurch 


98  SIXTH   INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

Gefahr  bringen.  Sorgfdltige  Controlle  des  Herzens,  Starkung  seines  Muskels 
durch  Digitalis  vor,  und  Campher  wahrend  und  nach  der  Operation,  konnen 
die  Gefahren  mindern.  Auch  scheint  mir  die  Durchfiihrung  der  Narcose, 
wie  Friedrich  sie  anwendet,  von  Wichtigkeit  zu  sein.  Er  gibt  20  Minuten 
vor  der  Operation  1-1^  cgr.  Morphium.  Das  Operationsgebiet  wird  durch 
Schleich'sche  Infiltrationsanasthesie  unempfindlich  gemacht.  Gleichzeitig 
wird  eine  ganz  oberflachliche  Cloroformtropfnarcose,  bei  der  durchschnittlich 
nur  1-15  cm.  Narcoticum  gebraucht  werden,  eingeleitet. 

Eine  zweite  Schattenseite  der  Operation  liegt  in  der  Entstellung  des 
Thorax.  Der  Verlust  einer  ganzen  Brustwand  kann,  namentlich  im  jugend- 
lichen  Alter,  nicht  gleichgiiltig  sein.  Ob  es  nach  langerer  Zeit  zu  Deformitaten 
der  Wirbelsaule  komrat,  muss  abgewartet  werden.  Ein  Vergleich  mit  den 
Empyemen  ist  nicht  zulassig.  Bei  diesen  ist  infolge  des  Narbenzuges  der 
Pleura  und  des  Aufeinanderriickens  der  Rippen  stets  die  Wirbelsaule  mit  der 
Concavitat  nach  der  kranken  Seite  hin  verkriimmt.  Diese  Skoliose,  die 
mitunter  betrachtliche  Grade  annehmen  kann,  schwindet  nach  der  Operation 
gewohnlich  sehr  bald,  wenn  ihre  veranlassende  Ursache  mit  der  Entfernung 
von  Pleura  und  Rippen  beseitigt  ist. 

Fur  das  Gelingen  dieser  Operation  ist  die  Auswahl  geeigneter  Falle  die 
Hauptvorbedingung. 

j\Ian  wird  diese  grossen  Operationen  nur  Patienten  zumuten,  die  sich  in 
ausgezeichnetem  Kraftezustand  befinden.*  Dabei  ist  von  grosser  Wichtig- 
keit, dass  es  sich  wirklich  in  der  Hauptsache  um  einseitige  Phthisen  handelt. 
Die  Operation  ist  dann  weiter  ausgeschlossen  bei  krankem  Herzen  und 
gleichzeitig  bestehender  Darmtuberkulose.  Schliesslich  wird  man  sich  iiber- 
haupt  zu  diesem  grossen  Eingriff  nur  dann  entschliessen,  wenn  die  iibrigen 
Behandlungsmethoden  versagt  haben. 

Ob  durch  Friedrich's  Operationsmethode  Dauererfolge  zu  erzielen  sind, 
steht  abzuwarten.  Bei  einer  so  eigenartigen  Krankheit,  wie  die  Tuberkulose, 
bei  der  voriibergehend  auch  spontane  Besserungen  eintreten  konnen,  ist  die 
strengste  Kritik  die  Voraussetzung  fiir  die  richtige  Beurteilung  des  Wertes 
einer  Behandlungsmethode.  AUerdings  lasst  der  von  Friedrich  erzielte 
unmittelbare  Erfolg  ein  Weiterarbeiten  auf  diesem  Gebiete  gerechtfertigt 
erscheinen. 

Damit  bin  ich  am  Schluss  meines  Referates  angelangt.  Ich  habe  die  von 
der  Kongress-Leitung  mir  gestellte  Aufgabe  zu  erledigen  versucht,  dadurch, 
dass  ich  eine  Ubersicht  gab  iiber  das,  was  bisher  auf  dem  Gebiete  der 
Lungentuberkulose  von  der  Chirurgie  geleistet  worden  ist,  und  was  wir 
iiberhaupt  von  ihr  zu  erwarten  haben. 

Die  positiven  Resultate  operativer  Behandlungen  der  Lungentuberkulose 
sind  noch  sehr  klein.  Aber  es  steht  zu  hoffen,  dass  mit  dem  wachsenden 
*  Die  naheren  Indikationen  sind  in  den  Friedrich'  schen  Arbeiten  zu  finden. 


LUNGENTUBERKULOSE,    CHIRURGISCHE    BEHANDLUNG. — SAUERBRUCH.      99 

Intresse  fiir  die  Thoraxchirurgie  auch  die  modernsten  Versuche,  die  Lungen- 
tuberkulose  operativ  zu  beeinflussen,  an  Bedeutung  gewinnen.  Ich  denke 
hier  in  erster  Linie  an  die  Freund'sche  Operation,  an  die  Pneumothoraxbe- 
handlung  und  an  die  "Entknochung"  der  Bmstwand.  Fiir  jeden  weiteren 
Fortschritt  ist  unbedingt  notwendig,  dass  innere  Kliniker  und  Chirurgen 
Hand  in  Hand  arbeiten;  und  die  Ausarbeitung  der  pracisen  Indicationen 
und  die  Erkenntnis,  welche  Operationsmethode  die  meiste  Aussicht  auf 
Erfolg  hat,  kann  nur  das  Produkt  gemeinsamer  Arbeit  sein. 


SECTION  III. 
Surgery  and  Orthopedics  {Continued), 


THIRD  DAY. 

Wednesday,  September  30,  1908. 

TUBERCULOSIS  OF  THE  BONES  AND  JOINTS. 


The  Section  was  called  to  order  by  the  President,  Dr.  Charles  H.  Mayo, 
at  half-past  nine  o'clock. 


TUBERCULAR  ARTHRITIS  OF  THE  HIP-JOINT. 

By  Stephen  H.  Weeks,  M.D., 

Portland,  Maine. 


The  term  hip-joint  disease  is  very  objectionable,  but  has  been  so 
long  in  use  and  is  so  generally  accepted  that  it  is  difficult  to  get  rid  of  it. 
Laennec  was  the  first  to  teach  that  some  joint  diseases  are  tubercular,  and 
he  was  soon  followed  by  Virchow  and  Volkmann.  Many  at  that  time 
believed  in  the  microbic  origin  of  tuberculosis,  but  none  could  prove  it 
until  1882,  when  Robert  Koch  discovered  the  tubercle  bacillus.  The  time 
has  long  since  passed  when  it  is  necessary  to  offer  proof  that  the  tubercle 
bacillus  is  the  cause  of  tuberculosis;  it  is  sufficient  here  to  say  that  it  is  al- 
ways found  where  tuberculosis  exists,  whether  in  the  lungs,  brain,  abdomen, 
bones,  or  joints,  and  that  artificial  tuberculosis  can  be  produced  by  injecting 
the  bacilli  into  animals.  The  facts  that  the  vast  majority  of  chronic  joint 
diseases  are  tubercular  and  that  the  bacillus  is  not  peculiar  to  certain  individ- 
uals have  a  practical  bearing  upon  the  diagnosis,  prognosis,  and  treatment 
in  these  cases.  It  should  be  constantly  borne  in  mind  that  joint  tuberculosis 
is  a  local  disease,  and  should  be  treated  as  such.  It  is  the  surgeon's  duty  to 
use  every  effort  to  prevent  this  local  disease  from  becoming  general.  It  is 
rarely  that  tubercular  joint  disease  ends  fatally,  except  when  some  other 
more  vital  part  becomes  secondarily  affected.     While  we  know  that  the 

100 


TUBERCULAR   ARTHRITIS   OF   THE   HIP-JOINT. — WEEKS.  101 

bacillus  is  the  cause  of  tubercular  joint  disease,  we  also  know  that  certain 
auxiliary  concUtions  are  necessary  for  the  development  of  a  local  tuberculosis. 
The  fact  that  tubercular  inflammation  is  so  frequent  in  children,  and  that  it 
begins,  as  a  rule,  in  some  center  of  growth  or  development,  would  indicate 
that  growing  tissue  offers  the  necessary  requirements  for  its  development. 
I  believe  that  an  injury,  in  the  vast  majority  of  cases,  offers  or  produces  the 
place  of  least  resistance  for  the  lodgment  and  development  of  the  tubercle 
bacillus  in  joint  disease,  because  I  have  seen  so  many  cases  in  which  the 
disease  could  be  directly  traced  to  an  injury  that  I  am  satisfied  that  the  same 
cause  exists,  frequently  when  overlooked.  Just  as  a  severe  injury  is  liable 
to  be  followed  by  the  ordinary  phenomena  of  an  acute  inflammation,  so  is  a 
sUght  injury  to  be  followed  by  a  tubercular  inflammation.  It  is  usually  the 
active  child  of  a  family,  who  is  most  subject  to  falls  and  accidents,  who 
develops  a  joint  tuberculosis.  The  fact  that  some  tubercular  taint  can  be 
found  in  the  family  history  proves  nothing,  for  few  families  are  free  from 
such  taint.  Tuberculosis  of  the  hip-joint  is  a  chronic  destructive  disease  that 
results  in  loss  of  function  and  deformity,  if  not  detected  in  its  early  stage 
and  treated  in  accordance  with  modern  methods. 

Pathology. 
Tuberculous  disease  of  the  hip- joint  usually  begins  in  several  minute 
foci  in  the  neighborhood  of  the  epiphyseal  cartilage  of  the  head  of  the  femur. 
Here  the  circulation  is  most  active,  and  here  the  newly  formed  bone  is  least 
resistant.  Thus  the  bacilli,  carried  by  the  blood-stream,  are  more  often  de- 
posited at  this  point,  where,  under  favoring  conditions,  induced  it  may 
be  by  slight  traumatism,  the  disease  is  established.  The  foci  coalesce,  and 
an  area  of  infected  granulations  replaces  the  normal  structures.  If  the  local 
resistance  is  sufficient,  the  disease  may  be  confined  to  the  interior  of  the  bone, 
but  in  most  instances  it  gradually  forces  its  way  into  the  joint,  and  the  granu- 
lation tissue,  spreading  under  and  over  the  cartilage,  destroys  it  in  its  prog- 
ress. The  lining  membrane  of  the  joint  becomes  involved  in  the  disease, 
and  finally  the  adjoining  surface  of  the  acetabulum  as  well.  In  a  certain 
number  of  cases  the  disease  begins  about  the  epiphyseal  junctions  in  the 
acetabulum,  and  the  primary  disease  may  begin  in  the  synovial  membrane, 
although  this  is  uncommon  in  children.  From  a  clinical  standpoint,  primary 
disease  of  the  acetabulum  may  be  inferred  when  the  patient  is  particularly 
susceptible  to  movements  of  the  trunk,  or  when  lateral  pressure  on  the  pelvis 
causes  pain;  or  when  a  Roentgen  picture  shows  greater  erosion  of  the  acetabu- 
lum than  of  the  head  of  the  femur.  As  a  rule,  however,  the  symptoms  may 
be  best  explained  by  primary  disease  of  the  head  of  the  thigh  bone.  The 
appearances  in  advanced  cases,  as  seen  at  operation  or  autopsy,  may  be  sum- 
marized somewhat  as  follows:  The  head  of  the  femur  is  deeply  eroded,  its 


102  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

cartilaginous  covering  has  practically  disappeared  or  is  in  part  still  adherent 
in  necrotic  shreds.  It  lies  in  seropurulent  fluid,  surrounded  by  the  gelatinous 
necrotic  granulations  that  line  the  capsule  and  partly  fill  the  enlarged  acet- 
abulum. In  certain  instances  the  pelvic  bones  may  be  diseased,  the  acet- 
abulum may  be  perforated,  or  the  shaft  of  the  femur  may  be  involved. 

Relative  Frequency.     Age.    Sex.     Side  Affected. 

Tuberculosis  of  the  hip- joint  is  the  most  common  and  the  most  important 
of  the  affections  of  the  joints,  ranking  second  to  Pott's  disease  of  the  spine. 
In  a  total  of  7841  cases  of  tuberculous  disease  treated  in  the  out-patient  de- 
partment of  the  Hospital  for  Ruptured  and  Crippled  in  New  York  city  in  the 
fifteen  years  from  1885  to  1899,  3203  were  Pott's  disease  and  2230  were  hip 
disease,  while  the  remaining  .2408  cases  included  all  the  other  joints. 

Hip-joint  disease  is  essentially  a  disease  of  early  childhood,  although 
no  age  is  exempt. 

Sex  exercises  but  little  influence,  although  the  disease  is  slightly  more 
common  among  males  than  among  females. 

In  disease  of  this  as  of  other  joints  the  right  is  somewhat  more  often 
affected  than  the  left. 

Etiology. 

Three  factors  are  recognized  in  the  etiology  of  tuberculosis :  the  infectious 
element  (the  tubercle  bacillus),  the  general  predisposition  of  the  patient, 
and  the  local  condition  that  favors  the  reception  and  growth  of  the  bacilli. 

Predisposition. — The  predisposition,  both  general  and  local,  is  spoken 
of  as  lessened  vital  resistance.  A  general  predisposition  to  this  disease  may 
be  inherited  or  it  may  be  acquired.  Thus  a  history  of  tuberculosis  in  the  im- 
mediate family  of  the  patient  is  supposed  to  imply  a  lessened  resistance  to 
this  form  of  disease.  In  a  certain  proportion,  perhaps  25  per  cent.,  of  the 
cases  this  inherited  predisposition  is  very  direct  and  positive,  but  in  the  larger 
number  the  family  history  is  as  indefinite  as  in  a  similar  class  of  patients 
under  treatment  for  any  other  form  of  ailment.  The  acquired  predisposition 
is  of  more  direct  importance,  since  it  would  include  the  lowering  of  the  vitality 
due  to  improper  food  and  improper  hygienic  surroundings  of  every  variety, 
together  with  the  greater  liability  to  depressing  diseases  and  the  more  con- 
stant exposure  to  tuberculous  infection  that  such  conditions  imply.  Thus 
tuberculous  disease  of  the  bones  and  joints,  as  well  as  other  parts,  is  more 
common  among  the  poor  of  cities  than  among  the  more  favored  classes. 

Mode  of  Infection. — The  tubercle  bacilli  may  be  introduced  into  the 
system  by  inhalation,  and  find  their  way  to  the  bronchial  glands,  or  by  the 
mouth,  and  set  up  disease  in  the  mesenteric  glands,  or,  after  infection  of  the 
nasal  passage  or  neighboring  parts,  secondary  disease  of  the  cervical  lymph- 
atics may  appear  in  the  so-called  scrofulous  glands  of  the  neck. 


tubercul.ajl  arthritis  of  the  hip. — weeks.  103 

Latent  Tuberculosis. 
It  may  be  assumed  that  disease  of  the  bronchial  and  mesenteric  glands 
is  not  uncommon  in  persons  of  apparently  perfect  health,  since  it  is  often 
discovered  at  autopsies  in  those  who  have  died  from  other  causes.  This 
form  of  glandular  disease  is  called  latent  tuberculosis,  and  it  usually  precedes 
a  local  outbreak  in  the  bone  or  elsewhere.  In  many  instances  the  disease 
may  remain  latent  and  finally  disappear,  or  it  may  persist,  and  from  time  to 
time  free  bacilli  or  bits  of  infected  tissue  may  escape  into  the  blood-current; 
by  it  they  are  deposited  in  other  parts,  where,  under  favoring  conditions, 
local  disease  may  be  set  up.  Depression  of  the  \'itality  from  any  cause  may 
be  supposed  to  favor  the  progress  of  the  glandular  disease,  which  may  lead 
to  a  dissemination  of  the  infectious  elements,  and  at  the  same  time  it  may 
lessen  the  resistance  of  other  tissues  that  may  be  exposed  to  the  infection. 
This  accounts  for  the  well-known  influence  of  certain  diseases,  such  as 
measles  and  whooping-cough,  not  only  in  predisposing  to  local  tuberculosis, 
but  in  favoring  its  progress  when  it  is  already  established.  It,  however, 
is  possible  that  the  bacilli  that  have  found  their  way  into  the  blood-current 
may  set  up  primary  disease  of  a  bone  or  joint.  In  fact,  it  is  stated  by  Konig 
that  in  14  out  of  67  autopsies  on  subjects  who  have  suffered  from  tu- 
berculous disease  of  the  bones  and  joints,  no  other  foci  were  found  in  the 
body.  And  in  other  instances  the  source  of  infection  may  be  preexistent 
disease  of  the  lungs  or  of  other  internal  organs. 

Symptoms. 
Tuberculous  disease  of  the  hip-joint  is  a  chronic,  insidious  affection, 
characterized  by  occasional  exacerbation  of  more  acute  symptoms  that 
are  induced  by  overstrain  or  injury,  by  a  more  rapid  advance  of  the  destruc- 
tive process,  or  by  infection  v/ith.  pyogenic  germs.  In  the  early  state  of  the 
disease  the  joint  is  simply  sensitive,  and  the  symptoms  vary  according  to  the 
activity  of  the  disease,  which  may  increase  the  tension  within  the  bone, 
the  susceptibility  of  the  patient,  and  the  strain  to  which  the  weakened  part 
is  subjected.  This  sensitiveness  is  shown  by  the  involuntary  adaptation 
of  the  body  to  the  weakness  of  the  affected  part,  or,  as  popularly  expressed, 
the  patient  favors  the  leg.  The  first  symptom  usually  noticed  is  a  slight 
limp.  A  limp  in  a  child  should  never  be  considered  a  trifling  affair,  but 
should  always  lead  to  a  careful  examination  of  the  lower  extremities,  because 
it  is  the  first  evidence  of  a  number  of  grave  diseases.  The  hip  limp  is  pecu- 
liar and  can  be  recognized  readily.  It  is  due  to  tenderness  and  muscular 
spasm.  The  spasm  reduces  the  amount  of  free  motion  in  the  joint,  and, 
when  the  patient  steps  forward  with  the  affected  liml),  instead  of  bending 
the  hip  freely,  he  bends  the  spine  and  swings  the  pelvis  and  the  limb  forward 
together.  Muscular  spasm  and .  consequent  limitation  of  motion  develop 
very  early  and  are  the  most  important  symptoms  from  a  diagnostic  stand- 


104  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

point.  This  spasm  is  probably  reflex,  and  is  due  to  irritation  of  the  nerves 
supplying  the  joint.  Nature  is  trying  to  put  the  joint  at  rest  by  placing  all 
the  muscles  on  guard.  This  constant  contraction  of  the  muscles  very  soon 
causes  deformity.  There  is  always  flexion,  sometimes  with  abduction  and 
outward  rotation,  but  more  frequently  with  abduction  and  inward  rotation. 
Where  abduction  is  present  at  first,  it  soon  changes  to  adduction.  This  change 
is  not  due  to  intra-articular  pressure,  because  it  takes  place  when  there  is  no 
effusion  in  the  joint.  It  is  undoubtedly  due  to  the  muscular  spasm.  When 
abduction  and  outward  rotation  are  present,  there  is  apparent  lengthening. 
The  affected  limb  seems  to  be  longer  than  its  fellow,  whether  the  child  is 
lying  on  his  back  or  standing.  The  position  is  due  to  tilting  of  the  pelvis. 
With  adduction  and  inw^ard  rotation  there  is  apparent  shortening.  In  the 
early  stage  of  the  disease  the  shortening  is  only  apparent,  but  later  may 
become  real,  on  account  of  destruction  of  the  head  of  the  bone.  Pain  may 
be  very  slight  or  very  severe  in  the  early  stage.  It  is  usually  a  prominent 
symptom,  and  is  most  frequently  located  at  the  inner  side  of  the  knee.  The 
patient  may  be  entirely  free  from  pain  all  day  and  yet  suffer  all  night.  When 
the  child  is  suffering  and  the  thigh  is  flexed,  he  will  usually  be  found  with 
the  bottom  of  the  foot  of  the  well  side  resting  on  the  instep  of  the  affected 
side,  making  an  effort  at  extension.  In  the  beginning  of  what  is  sometimes 
called  the  second  stage,  all  the  symptoms  of  the  early  stage  are  exaggerated. 
The  deformity  is  increased,  and  the  shortening  may  be  real.  Pain  is  a  con- 
stant symptom,  and  the  "night-cries"  begin.  This  night-cry  is  quite  pecu- 
liar: it  is  a  loud  shriek,  occurring  when  the  child  is  asleep.  The  cry  may  be 
so  loud  as  to  waken  others,  but  the  child  may  not  waken.  It  is  probably 
due  to  a  sudden  spasm  of  the  muscles,  causing  pain  of  short  duration.  Ab- 
duction may  be  present,  but  adduction  is  the  usual  position.  The  deformity 
is  well  marked  and  atrophy  is  decided.  The  limp  is  increased,  and  the  patient 
may  not  be  able  to  stand  upon  the  limb.  The  gluteofemoral  crease  has  en- 
tirely disappeared,  and  the  joint  is  quite  fixed.  In  fact,  the  symptoms  are  all 
so  well  marked  that  the  laity  can  make  the  diagnosis.  Unfortunately,  it  is 
at  this  late  stage  that  the  child  is  brought  to  the  surgeon.  In  addition  to 
the  symptoms  that  have  been  described  we  may  have  suppuration  and 
abscess,  and,  if  the  joint  can  be  moved,  crepitation  may  be  felt.  The  original 
focus  of  disease  has  broken  down,  and  all  the  joint  structures  are  involved. 
Abscess  as  a  complication  occurs  in  a  large  percentage  of  cases  that  have 
not  been  recognized  and  properly  treated  in  the  early  stage  of  the  disease. 
The  presence  of  an  abscess  usually  indicates  that  suppuration  is  going  on  in 
the  joint,  although  it  may  be  entirely  peri- articular,  owing  to  the  breaking 
of  the  original  focus  outside  of  the  capsule  of  the  joint.  At  this  stage  of 
the  disease  a  peri-arthritis  is  present  and  can  usually  be  felt  around  the 
trochanter.    There  is  fever,  the  temperature  running  from  99°  to  102°  F., 


TUBERCUL.\R   ARTHRITIS    OF   THE   HIP. — WEEKS.  105 

and  is  greatest  when  the  abscess  has  opened  and  sinuses  are  present.  At 
the  time  when  the  original  focus  breaks  through  into  the  joint,  there  is  a 
decided  rise  of  temperature,  and  after  an  abscess  has  broken  externally,  the 
patient  suffers  from  a  rise  of  temperature,  due  to  infection  of  the  abscess- 
cavity  b}^  pyogenic  germs.  This  usually  disappears  after  a  few  days,  but 
occasionally  the  patient  rapidly  emaciates  and  dies,  the  high  temperature 
continuing  until  death.  During  the  later  stage  of  the  disease  the  general 
health  suffers  greatly,  and  death  occurs  from  tubercular  meningitis,  pul- 
monary tuberculosis,  and  amyloid  changes  in  the  liver  and  kidneys. 

Diagnosis. 
The  diagnosis  offers  no  difficulty  when  the  symptoms  are  all  well  marked 
and  when  the  characteristic  deformity  is  present,  but  it  is  of  the  utmost 
importance  that  it  be  made  at  an  early  date  in  order  that  the  treatment  may 
be  successfully  applied.  The  temperature  offers  no  help  in  diagnosis,  be- 
cause it  varies  so,  and  may  be  entirely  absent.  The  pain  located  at  the  inner 
side  of  the  knee  is  suggestive,  but  not  conclusive.  The  fact  that  no  pain 
exists  is  no  proof  of  the  absence  of  hip-joint  disease,  because  cases  occur 
without  pain.  Deformity  helps  to  make  a  diagnosis,  but  it  is  important  to 
make  the  diagnosis  before  this  symptom  is  well  marked.  A  certain  amount 
of  deformity  occurs  at  a  very  early  date.  Another  valuable  symptom 
is  muscular  spasm.  The  spasm  is  gentle,  involuntary  jerking  in  the  opposite 
direction  from  that  in  which  the  liml)  is  being  moved.  It  is  a  very  constant 
symptom,  but  should  be  noted  early  in  the  examination,  since  repeated 
manipulations  tire  the  muscle  so  that  the  spasm  may  disappear  for  a  time. 
When  involuntary  resistance,  to  motion  in  every  direction  is  present  with 
muscular  spasm,  the  joint  is  diseased  beyond  question ;  for  while  many  things 
may  interfere  with  motion  in  certain  directions,  notliing  else  will  give  this 
complete  train  of  sj^mptoms.  Spasm  will  be  found  in  all  stages  of  the  dis- 
ease, so  long  as  any  motion  in  the  joint  remains,  and  its  disappearance  is 
evidence  of  recovery.  These  manipulations  can  be  satisfactorily  performed 
upon  patients  of  any  age,  if  the  surgeon  exercises  patience  and  confines  liis 
manipulations  to  the  sound  limb  until  he  has  gained  the  patient's  confidence. 
The  family  history  is  of  no  value  in  making  a  diagnosis;  in  fact,  it  is  rather 
misleading.  The  general  condition  of  the  patient  is  rarely  of  value  in 
diagnosis,  since  the  general  health  is  rarely  affected  until  the  disease  is  well 
advanced.  A  number  of  affections  are  to  be  differentiated  from  hip-joint 
disease.  It  is  very  frequently  pronounced  rheumatism,  but  should  not  be, 
because  rheumatism  is  an  acute  polyarticular  disease.  Pott's  disease  in 
the  lumbar  region  may  be  mistaken  for  hip  disease,  for  at  a  very  early  period 
it  is  occasionally  difficult  to  make  a  differential  diagnosis  between  these  two 
affections.     In  Pott's  disease  there  is  the  characteristic  rigidity  of  the  spine, 


106  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

and  except  where  a  psoas  abscess  is  crowding  directly  upon  the  joint,  the 
limitation  of  motion  is  in  extension  only,  motion  in  the  other  directions  being 
quite  free.  The  patient  can  stand  upon  the  limb  without  causing  pain, 
and  manipulation  of  the  hmb  does  not  cause  spasm  except  in  extension. 

Atrophy. — Atrophy  is  an  important  sign  of  hip- joint  disease.  It  is 
often  appreciable  to  the  eye  and  to  the  hand,  and  is  always  demonstrable  by 
measurement.  It  is  an  important  symptom  because,  if  well  marked,  it 
shows  that  the  disease  must  have  existed  for  some  time,  whatever  may  be 
the  statement  of  the  patient's  relatives.  The  atrophy  affects  the  muscles 
of  the  entire  limb,  although  it  is  somew^hat  more  marked  in  the  muscles  of  the 
thigh  than  in  the  calf.  In  the  ordinary  ease  of  hip  disease  in  childhood, 
when  the  patient  is  first  brought  for  treatment,  it  averages  from  one-half 
to  one  inch  in  the  thigh,  and  somewhat  less  in  the  calf. 

The  x-Ray  in  Diagnosis. — Roentgen  pictures  are  of  far  more  value  in 
demonstrating  deformity  than  in  establishing  early  diagnosis  of  disease, 
especially  at  the  hip  in  early  childhood,  when  so  large  a  part  of  the  extremity 
of  the  femur  is  cartilaginous.  The  a:-ray  pictures  are  of  value,  however, 
in  shomng  the  destructive  effect  of  the  disease  on  the  head  of  the  femur  or 
acetabulum,  and  thus  giving  one  a  clearer  conception  of  the  actual  condition 
of  the  joint  than  would  be  possible  otherwise.  In  older  subjects  it  might  be 
possible  to  demonstrate  the  presence  of  disease  in  the  interior  of  the  bone 
by  this  means,  but  in  any  event  Roentgen  pictures  are  of  value  only  when 
interpreted  by  knowledge  of  the  physical  signs. 

Treatment. 

The  treatment  of  hip-joint  disease  may  be  divided  into  constitutional  and 
local.  If  mentioned  according  to  their  importance,  it  would  be  local  and 
constitutional.  It  should  be  remembered  always  that  it  is  primarily  a  local 
inflammation  and  should  be  treated  as  a  local  affection. 

The  local  treatment  is  either  mechanical  or  operative.  IMechanical  treat- 
ment is  applicable  in  the  vast  majority  of  cases.  The  great  principle  of 
treatment  in  this  disease  is  rest,  and  the  mechanism  that  carries  out  this 
principle  best  is  the  one  that  should  be  chosen.  The  best  results  are  not  to  be 
obtained  by  applying  exactly  the  same  variety  of  appliance  to  every  case. 
There  are  those  who  advocate  traction  and  those  who  advocate  fixation. 
Both  methods  have  their  place  in  the  treatment  of  this  affection.  The  great 
advantage  in  simple  fixation  is  that  it  can  be  secured  by  simple  means  that  are 
always  at  hand,  and  that  can  be  applied  by  comparatively  inexperienced 
hands,  while  traction  without  confining  the  patient  to  bed  can  only  be  secured 
by  special  appliances  that  require  special  skill  in  their  application.  While 
the  majority  of  cases  can  be  successfully  treated  by  simple  fixation,  a  certain 
number  will  continue  to  suffer  pain  and  do  badly  until  traction  is  applied. 


TUBERCULAR   ARTHRITIS   OF   THE   HIP. — WEEKS.  107 

On  the  other  hand,  there  are  cases  that  do  better  with  fixation  than  with 
traction.  The  fact  that  the  advocates  of  traction  and  of  fixation  each  claim 
the  superiority  of  their  respective  methods  by  statistics  from  their  practice, 
simply  shows  that  each  has  acquired  special  skill  in  the  use  of  his  favorite 
method,  and  has  given  the  method  credit  which  properly  belongs  to  his  skill. 
If  the  best  results  of  representatives  of  each  faction  be  compared,  they  will 
be  found  to  be  practically  the  same.  I  believe  that  the  surgeon  who  is  without 
prejudice  in  this  matter,  and  who  will  select  his  cases  for  the  respective 
methods,  will  secure  the  best  average  results.  When  first  called  to  a  patient 
who  is  suffering  severely  and  who  has  marked  deformity,  the  surgeon  can  afford 
his  patient  the  quickest  and  wisest  relief  by  putting  him  in  bed  and  applying 
traction  by  means  of  weight  and  pulley,  usually  called  Buck's  extension. 
The  amount  of  weight  varies  with  the  size  of  the  patient  and  in  different  cases. 
When  the  patient  is  a  cliild,  half  a  brick  is  a  good  weight  to  begin  with,  and  it 
is  rarely  necessary  to  apply  more  than  two  bricks  to  an  adult,  for  it  is  not 
so  much  the  amount  of  the  traction  as  its  persistency  that  overcomes  spasm. 
A  bag  of  sand  is  a  very  convenient  weight,  since  it  can  be  so  easily  made 
lighter  or  heavier,  to  meet  indications.  The  amount  of  weight  in  a  given  case 
should  be  just  what  the  surgeon  finds  will  overcome  the  muscular  spasm  and 
relieve  the  pain;  too  much  weight  will  cause  the  patient  more  pain.  The 
tendency,  on  the  part  of  the  patient,  to  slide  down  in  bed  can  be  best  overcome 
by  elevating  the  foot  of  the  bed  from  two  to  four  inches.  Theoretically,  the 
traction  should  be  in  line  with  the  deformity,  but  practically  I  have  found 
that  it  is  rarely  necessary  to  make  any  special  provision  for  this,  since  the 
patient  will  place  himself  in  bed  in  such  a  position  as  affords  him  the  most 
relief  and  does  him  the  most  good. 

If  taken  in  the  early  stage,  two  or  three  weeks  in  bed  with  proper  extension 
will  usually  be  sufficient  to  relieve  the  pain  and  overcome  deformity.  A  cliild 
that  has  been  suffering  without  proper  treatment  until  it  has  become  emaci- 
ated will  often  regain  its  flesh  very  rapidly  under  this  plan  of  treatment. 
The  patient  should  be  gotten  out  of  bed  as  soon  as  possible,  so  that  he  can 
have  the  benefit  of  outdoor  life.  When  the  deformity  yields  promptly  to  tliis 
treatment  in  bed,  and  the  joint  is  not  exceptionally  sensitive,  the  chances 
are  that  a  fixation  apparatus  will  bring  the  case  to  a  favorable  termination. 
I  usually  apply  plaster-of-Paris  from  just  above  the  knee  to  the  ribs.  This 
material  is  chosen  because  it  is  always  at  hand,  and  can  be  quickly  and  easily 
applied,  and  because  it  yields  good  results.  It  is  a  great  boon  in  charity 
work  because  of  its  cheapness.  The  plaster  should  be  applied  over  a  close- 
fitting  garment  or  a  layer  of  bandage,  and  should  be  heavy  enough  to  have 
the  necessary  strength  without  being  a  burden.  The  shoe  on  the  well  side 
should  be  elevated  from  2^  to  3^  inches,  and  a  pair  of  crutches  used;  for  if 
there  is  not  plenty  of  elevation,  the  child  will  begin  to  use  the  affected  limb 


108  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

as  soon  as  the  weight  upon  it  does  not  cause  decided  pain.  The  cheapest 
and  best  way  to  elevate  the  shoe  is  to  have  a  block  of  light  wood  the  shape 
of  the  sole  of  the  shoe,  and  of  the  proper  weight,  hollowed  out  so  as  to  make 
it  as  light  as  possible,  and  fastened  to  the  bottom  of  the  shoe  by  screws 
coming  through  from  the  inside  of  the  shoe.  This  block  can  be  painted 
black  and  can  be  made  very  presentable.  If  something  better  is  desired, 
a  cork  sole  covered  with  leather  is  best.  It  is  needless  to  say  that  the  elevated 
shoe  should  be  on  the  well  limb.  The  patient  must  be  under  the  constant 
care  and  supervision  of  a  competent  ph3^sician  until  all  pain  and  spasm  are 
gone,  which  will  vary  from  six  months  to  two  years. 

Constitutional  Treatment. — If  there  is  one  point  that  has  been 
emphasized  by  the  newer  ideas  on  the  treatment  of  tuberculosis,  it  is  that 
ever}i;hing  must  be  done  to  strengthen  the  defenses  of  the  system  against 
the  encroachments  of  the  tubercle  bacilli;  whether  it  is  pulmonary  tuber- 
culosis or  tuberculosis  of  joints,  the  salient  idea  is  to  increase  the  vital  re- 
sistance by  fresh  air,  sunUght,  and  proper  nutrition.  To  a  great  extent 
this  plan  holds  good  in  surgical  tuberculosis,  and  it  is  only  necessar)'-  to  in- 
stance the  remarkable  results  that  have  been  achieved  in  recent  years  in 
cases  of  tuberculosis  of  the  various  joints  by  an  outdoor  life,  particularly  at 
the  seaside,  and  without  resort  to  operative  measures.  Tuberculosis  is  still 
a  battle-ground  between  what  might  be  termed  the  radical  surgeons,  who  see 
in  every  tuberculous  focus  a  lesion  which  must  be  thoroughly  removed, 
and  those  who  maintain  a  more  conservative  attitude,  considering  operation  as 
only  one  of  the  elements  in  the  treatment.  In  the  Bradshaw  lectures,  Mr. 
R.  J.  Godlee,  of  London,  expresses  himself  in  general  as  favorably  inclined 
toward  the  new  vaccine  therapy  in  tuberculosis;  his  experience  leads  him 
to  state  that  it  is  impossible  at  the  present  time  to  promise  uniformly  good 
results,  and  that  he  is  far  from  convinced  that  it  is  destined  to  replace  all  other 
medical  and  surgical  measures.  When  it  is  considered  that  many  cases  of 
tuberculosis  in  different  parts  of  the  body  recover  under  hygienic  treatment 
alone,  and  that  no  treatment  can  restore  what  has  been  irreparably  destroyed 
by  disease,  it  cannot  be  expected  that  vaccine  therapy  will  prove  more  than 
a  valuable  adjunct  to  other  treatment. 


Arthritis  Tuberculosa  de  la  Cadera. — (Weeks.) 
El   tratamiento   local  se  divide  en  tratamiento  mecanico   y   operative. 

El  gran  principio  del  tratamiento  local  es  el  descanso  de  la  parte  afectada. 

Esta  puede  hacerse  por  medio  de  la  traccion  6  por  la  fijacion  segun  las  indi- 

caciones  del  caso, 

Tratamiento  Constitucional. — Si  existe  un  punto  de  verdadera  impor- 

tancia  en  las  ideas  modernas  sobre  el  tratamiento  de  la  tuberculosis,  6ste 


TXJBEECULAE.   ARTHEITIS   OF   THE   HIP. — WEEKS.  109 

es  el  hacer  todos  los  esfuerzos  en  la  fortificacion  del  organismo  contra  la 
invasion  del  bacilo  de  la  tuberculosis:  bien  que  la  afeccion  sea  pulmonar 
6  de  las  articulaciones,  la  idea  saliente  es  de  aumentar  las  resistencias  vitales 
por  medio  del  aire  puro,  los  rayos  solares  y  una  nutricion  apropiada.  Re- 
sultados  remarcables  se  han  obtenido  ultimamente  en  los  casos  de  tubercu- 
losis en  las  diferentes  articulaciones  por  medio  de  la  vida  al  aire  libre,  partic- 
ularmente  a  las  orillas  del  mar,  sin  tener  necesidad  de  recurir  a  las  medidas 
operativas. 

En  las  conferencias  de  Bradshaw,  Mr.  R.  J.  Godlee,  de  Londres,  se  ex- 
presa  en  un  sentido  favorable  hacia  las  medidas  terapeuticas  de  la  vacuna 
en  el  tratamiento  de  la  tuberculosis.  Al  presente  solo  podemos  decir  que 
este  procedimiento  puede  talvez  Uegar  a  ser  un  ad  junto  a  los  otros  trata- 
mientos. 

Arthrite  Tuberculeuse  de  la  Hanche. — (Weeks.) 
Le  traitement  local  se  divise  en  traitement  mecanique  et  operatoire. 
Le  grand  principe  du  traitement  local,  c'est  le  repos  de  rarticulation  affectee. 
On  peut  I'obtenir  par  traction  et  fixation,  Tun  ou  I'autre,  ou  tons  les  deux, 
suivant  les  indications. 

Traitement  Constitutionnel. — S'il  est  une  chose  d^montree  par  les  prin- 
cipes  les  plus  recents  du  traitement  de  la  tuberculose,  c'est  qu'il  ne  faut  rien 
negliger  pour  augmenter  la  resistance  du  systeme  a  I'invasion  du  bacille 
tuberculeux:  qu'il  s'agisse  de  la  tuberculose  pulmonaire  ou  de  la  tuberculose 
articulaire,  I'id^e  dominante  est  d'accroitre  la  resistance  vitale  par  le  grand 
air,  le  soleil  et  une  alimentation  convenable.  On  a  obtenu  r^cemment  des 
resultats  remarquables  dans. les  differents  cas  de  tuberculose  articulaire  par 
la  vie  au  grand  air,  surtout  au  bord  de  la  mer,  sans  recourir  aux  moyens 
operatoires. 

Dans  les  conferences  Bradshaw,  M.  R.  J.  Godlee,  de  Londres,  se  declare 
g^neralement  en  faveur  de  la  nouvelle  therapie  vaccinale  dans  le  traitement 
de  la  tuberculose.  Tout  ce  que  nous  pouvons  dire  a  I'heure  presente,  c'est 
qu'elle  peut  aider  consid^rablement  les  autres  traitements. 


Tuberculose  Arthritis  des  Hiiftgelenks. — (Weeks.) 

Behandlung — locale  und  allgemeine. 

Locale  Behandlung  kann  eine  mechanische  oder  operative  sein.  Das 
Hauptprincip  bei  localer  Behandlung  ist  die  Ruhe  fiir  das  afficirte  Gelenk. 
Dieselbe  kann  bewerkstelligt  werden  entweder  durch  Zug,  oder  durch 
Fixation,  oder  durch  beides  zugleich,  je  nach  der  Indication  in  gegebenem 
Falle. 

Allgemeine  Behandlung. — In  den  neueren  Ansichten  iiber  Behandlung 


110  SIXTH    INTERNATIONAL    CONGRESS    ON   TUBERCULOSIS. 

der  Tuberculose  tritt  ein  Punkt  mit  besonderer  Nachdriicklichkeit  in  den 
Vordergrund,  niimlich:  dass  alles  gethan  werden  muss,  um  die  im  Korper 
vorhandenen  Schutzmittel  gegen  das  Eindringen  der  Tuberkelbacillen  zu 
kraftigen.  Ob  es  sich  um  Lungentuberculose  handelt  oder  um  Tuberculose 
der  Gelenke,  immer  muss  das  Hauptbestreben  bleiben,  durch  frische  Luft, 
Sonnenlicht,  und  angemessene  Nahrung  die  vorhandene  vitale  Widerstands- 
fahigkeit  zu  erhohen.  Bemerkenswerthe  Resultate  sind  in  den  letzten 
Jahren  bei  Tuberculose  der  verschiedenen  Gelenke  erreicht  worden  durch 
Aufenthalt  in  frischer  Luft,  besonders  am  Meeresstrande,  und  ohne  von 
operativen  Eingriffen  Gebrauch  zu  machen.  Herr  R.  J.  Godlee,  in  London, 
hat  sich  bei  Gelegenheit  der  Bradshaw  Vortrage  im  allgemeinen  zu  Gunsten 
der  neuen  Behandlung  der  Tuberculose  durch  Impfung  ausgesprochen. 
Alles  was  man  zur  Zeit  dariiber  sagen  kann  ist,  dass  dieselbe  sich  vielleicht 
als  werthvolles  Hiilfsmittel  neben  anderen  Behandlungsmethoden  erweisen 
wild. 


DISCUSSION. 

Dr.  Willy  Meyer  (New  York)  said  there  could  be  no  doubt  that  in  the 
last  twenty-five  years  the  pendulum  had  swung  toward  conservatism  in  the 
treatment  of  these  cases.  In  the  beginning  of  antisepsis,  thirty  years  ago, 
almost  every  surgeon  attacked  the  hip- joint  by  means  of  resection.  So  far 
it  had  been  impossible  successfully  to  apply  the  Bier  treatment  to  the  hip- 
joint.  The  hip-joint  was  supplied  by  the  internal  iliac  vessels,  and  the  iliac 
vein  could  not  be  compressed.  He  had  made  attempts  to  compress  the  in- 
ferior vena  cava.  This  was  difficult  and  painful,  and  yet  he  believed  this 
was  the  only  solution  of  the  problem.  It  might  be  possible  to  construct  cups, 
but  they  would  have  to  fit  very  snugly  about  the  hip.  Many  links  were 
necessary  to  complete  the  chain  in  the  treatment  of  tuberculosis — and  tu- 
berculin, hyperemia,  and  hygienic  and  dietetic  treatment  were  very  impor- 
tant links  in  this  chain. 

Dr.  John  Lindahl  (Denver,  Colorado)  said  there  was  an  important  an- 
atomic fact  in  connection  with  joint  disease,  and  that  was  that  the  joint  was 
supplied  by  the  same  nerve  that  supplied  the  surrounding  muscles.  This 
accounted  for  the  spasm  of  the  muscles  in  these  cases.  These  spasms  were 
particularly  injurious  at  night.  To  control  these  spasms  he  had  been  in 
the  habit  of  using  a  firm  bandage  applied  to  the  thigh  and  hip.  He  had  also 
used  a  canvas  casing,  which  could  be  buckled  on.  He  had  never  been  able 
to  apply  a  plaster-of-Paris  dressing  that  would  control  the  spasms  for  more 
than  three  or  four  days,  because  there  was  always  a  tendency  for  it  to  become 
loose  on  account  of  the  absorption  of  the  fat. 


THE   TREATMENT   OF  TUBERCULOUS    HIP    DISEASE 

BY  WEIGHT-BEARING  AND  FIXATION  BY  THE 

LORENZ   SHORT   HIP   SPICA. 

By  H.  Augustus  Wilson,  M.D., 

Professor  of  Orthopedic  Surgery,  Jefferson  Medical  College,  Philadelphia. 


The  discover)^  of  the  bacillus  of  tuberculosis  by  Koch  in  1882  marked  an 
important  epoch  in  bone  tuberculosis.  Historically,  much  of  interest  could 
be  related  regarding  the  various  forms  of  treatment,  which  seemed  to  be 
based  upon  accomplishing  inactivity.  At  the  present  date,  after  years  of 
labor  with  various  sera,  little  evidence  of  a  specific  remedy  is  advanced. 
Serum-therapy  is  of  undoubted  value  both  in  diagnosis  and  in  treatment. 
Tuberculous  hip  disease  has  been  a  most  difficult  problem  to  the  surgeon, 
and  a  greater  one  to  the  patient.  A  brief  discussion  of  the  generally  ac- 
cepted basic  principles  of  treatment  is  quite  essential  before  considering  the 
advantages  of  the  weight-bearing  method. 

It  has  been  customary  to  aim  at  securing  absolute  rest  for  the  affected  hip 
by  placing  the  patient  in  bed,  usually  for  months  at  a  time.  In  addition, 
extension  was  applied  so  as  to  overcome  muscle-spasm  and,  as  many  errone- 
ously thought,  to  separate  the  articulating  surfaces  of  the  joint.  Later, 
as  the  pain  subsided  and  the  patient  showed  improvement,  the  extension 
brace  was  applied,  allowing  the  patient  to  use  crutches  while  walking  on  the 
unaffected  limb.  It  is  quite  obvious  that  the  confinement  to  bed  and  the 
inactive  life  were  accountable  for  the  frail  and  anemic  condition  of  so  many  of 
these  patients.  In  like  manner  abscess  formations,  chronic  sinuses,  patho- 
logical dislocations,  and  secondary  involvements  can  be  accounted  for. 
Since  the  introduction  of  fresh  air,  sunlight,  and  dietetic  therapy,  the  end- 
results  have  been  of  a  higher  order.  Amyloid  degeneration  does  not  appear 
to  be  of  the  same  frequency  as  heretofore.  Patients  rarely  become  emaciated 
to  the  extent  formerly  observed. 

In  1902  I  became  mildly  impressed  by  the  statement  of  Lorenz,^  "No- 
body has  a  right  to  place  a  coxitic  child  in  bed  because  it  has  a  diseased  hip, 
for  almost  invariably  its  health  will  fail,"  and  later  by  his  two  papers" 
advocating  weight-bearing  with  the  short  spica.  I  now  believe  that  it  should 
be  the  preferable  method,  to  the  exclusion  of  all  forms  of  inactivity,  modified 
only  when  peculiar  conditions  of  pain,  etc.,  demand  temporary  rest. 

Ill 


112  SIXTH    INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

I  am  convinced  that  a  joint  that  has  had  its  articulating  surfaces  exten- 
sively denuded  by  a  pathological  process  is  not  capable  of  function,  and 
friction  should  be  avoided.  The  continued  friction  of  such  joints  tends  to 
increase  irritation.  Motion  should  be  inhibited,  and  ankylosis  secured,  by 
conserv^ative  measures  if  possible,  or  by  operative  procedure  if  necessary. 
Definite  proof  exists  that  prolonged  fixation  of  a  normal  joint  not  involved 
in  an  inflammatory  process  does  not  produce  ankylosis.  Quite  similarly,  a 
joint  that  is  the  site  of  a  tuberculous  osteitis  does  not  necessarily  become 
ankylosed  by  fixation  during  a  period  of  three  years.  It  is  apparent  that  the 
employment  of  the  spica  does  not  necessarily  result  in  ankylosis.  Resolu- 
tion may  take  place  without  extensive  destruction  of  joint  surfaces,  and  a 
movable  joint  may  result  where  recovery  follows  the  early  recognition  and 
early  adoption  of  the  methods  here  advocated.  It  has  always  been  observed 
that  children  with  hip  tuberculosis  would  step  upon  the  foot  upon  the  affected 
side  whenever  they  could  do  so  without  pain,  and  this  could  not  be  prevented 
by  braces  or  crutches.  It  is  not  uncommon  for  an  orthopedic  surgeon  to 
see  cases  of  ankylosis  of  the  hip  following  tuberculous  disease  in  which,  from 
failure  of  recognition  or  otherwise,  no  treatment  has  ever  been  employed. 
The  so-called  "nature's  cure"  is  only  objectionable  in  the  sense  that  the 
deformity  is  usually  an  unfavorable  one,  requiring  correction  by  operative 
means.  The  treatment  of  tuberculous  hip  disease  by  the  short  spica  pos- 
sesses all  the  advantages  of  "nature's  cure,"  assisted  by  fixation,  so  as  to 
prevent  an  unfavorable  deformity  and  supplemented  by  rational  hygiene. 
The  patient  walks  about  without  the  use  of  crutches,  and  activity  is  en- 
couraged. This  apparently  radical  departure  from  the  principles  previously 
advocated  may  seem  quite  erroneous  to  many,  but,  after  careful  considera- 
tion of  its  ultimate  effects,  will  appear  more  plausible  and  rational. 

The  excellent  results  obtained  by  Bier's  hyperemic  treatment  require 
deep  thought  in  relation  to  tuberculous  hip  disease.  Bier  has  proved  that 
a  large  blood-supply  to  a  part  is  almost  invariably  detrimental  to  the  prog- 
ress of  organisms,  and  increases  the  resistance  to  invasion.  Weight- 
bearing  is  conducive  to  the  benefits  obtained  by  outdoor  life,  and,  in  turn, 
prevents  circulatory  stasis,  thereby  securing  the  benefits  obtained  by  the 
hyperemic  method  of  Bier.  Objection  has  been  raised  that  such  ambula- 
tory methods  tend  to  induce  pathological  dislocation,  because  a  bone  affected 
with  tuberculosis  is  soft  and  will  yield  to  pressure.  Experience  has  shown 
that  when  the  affected  part  is  placed  in  the  proper  position,  pathological 
dislocation  does  not  occur  with  the  same  frequency  as  has  been  noted  in 
cases  where  it  appeared  to  depend  solely  upon  muscular  actions.  It  is  a 
weU-known  fact  that  pathological  dislocations  occurred  with  much  more 
frequency  prior  to  the  employment  of  the  ambulatory  method  of  treatment, 
proving  that  weight-bearing  is  not  necessarily  an  etiological  factor  in  its 


WEIGHT-BEARING   AND    FIX^^'iTION   IN    HIP    DISEASE. — WILSON.  113 

production.  As  aforesaid,  I  believe  improper  position  and  grinding  of  joint 
surfaces  are  causative  factors.  The  location  of  the  lesion  is  none  the  less 
important,  for  it  is  well  known  that  if  the  acetabulum  is  primarily  involved, 
more  difficulty  is  usually  encountered  than  if  the  disease  is  located  in  the 
trochanter  or  cervical  epiphysis.  In  treating  these  cases,  however,  no  clini- 
cal distinction  is  made  even  after  locating  the  lesion  by  the  radiograph. 
The  best  results  are  obtained  in  the  incipient  cases  and  those  involving  other 
anatomical  structures  than  the  acetabulum.  In  considering  the  dried  speci- 
mens in  the  various  museums  all  over  the  world,  one  must  be  impressed  with 
the  evidence  of  destructive  grinding  and  friction  in  joints  whose  surfaces 
were  largely  destroyed  bj'  the  former  tuberculous  osteitis,  and  reach  a  decision 
as  to  whether  such  joints  would  not  have  been  better  ankylosed. 

Adams'^  has  found  that  ambulatory  cases  of  tuberculous  joints  do  better 
than  those  confined  and  inactive.  The  reason  for  this  is  quite  apparent,  as 
was  aforementioned.  The  advantage  of  treating  these  cases  by  the  plaster 
spica  is  briefly  described  by  Ely:^  "It  dispenses  with  the  aid  of  the  brace- 
maker;  it  does  not  require  constant  supervision;  it  is  not  unsightly;  it  per- 
mits the  patient  to  use  the  limb  in  walking,  and  so  avoids  extreme  atrophy, 
that  always  accompanies  the  use  of  the  extension  splint.  Its  objections: 
first,  it  can  rarely  be  used  when  an  open  abscess  is  present  with  much  dis- 
charge; secondly,  it  requires  some  skill  in  its  application."  The  proof  of  the 
efficacy  of  this  method  is  strongly  manifested  by  the  increase  in  general 
health  and  gain  in  weight,  the  marked  muscular  development  of  the  affected 
leg,  which  frequently  necessitates  the  change  of  cast.  It  is  quite  obvious 
that  flexion  and  extension  of  the  leg,  movement  of  the  upper  trunk,  and  am- 
bulation are  conducive  to  the  much-wanted  blood-supply.  I  have  elsewhere 
reviewed  at  length  the  advantages  of  outdoor  life  versus  confinement  in  the 
treatment  of  bone  tuberculosis.^" 

It  would  simply  be  repetition  to  review  the  character  of  climate  and  forms 
of  diet,  but  it  must  be  a  foregone  conclusion  that  if  hygiene  is  neglected  and 
diet  not  considered,  the  treatment  of  these  cases  will  not  terminate  favorably. 
Carling^  says:  "Open-air  treatment  is  not  a  fad;  it  is  an  absolute  necessity 
for  the  speedy  and  permanent  cure  of  tuberculous  and  other  forms  of  bone 
and  joint  disease.  In  brief,  sunlight,  fresh  air,  and  activity  are  essential, 
milk  and  egg  diet  quite  as  important,  though  forced  feeding  I  do  not  advo- 
cate. Tonics  are  of  little  service  and  are  rarely  indicated.  Sanatoriums 
are  by  no  means  essential,  but  home  life  with  proper  outdoor  therapy  is 
preferable."  Suitable  well-ventilated  sleeping  arrangements  can  easily  be 
secured  in  almost  any  room. 

The  most  desirable  position  for  fixation  of  the  leg  by  the  spica  is  that  of 
twenty  degi-ees  of  flexion,  twenty  degrees  abduction,  and  five  degrees  ex- 
ternal rotation.    This  posture  overcomes,  to  a  certain  extent,  any  shorten- 


114  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

ing,  should  it  occur;  it  directs  pressure  toward  the  center  of  the  acetabulum, 
and  facilitates  ambulation.  The  plaster-of-Paris  spica  is  applied,  extending 
from  the  margin  of  the  ribs  to  the  knee.  In  cases  where  muscular  spasm 
requires  temporary  relief  the  cast  may  be  carried  below  the  knee,  and  subse- 
quently changed  when  the  spasm  passes  away.  It  has  been  a  matter  of 
frequent  observation  that  the  casts  become  too  tight  in  patients  who  have 
been  inactive  previously,  and  this  necessitates  a  renewal  of  the  cast.  The 
explanation  of  this  was  found  to  be  the  extensive  muscular  development  of 
the  leg,  due  to  its  activity,  thereby  indicating  the  great  advantages  being 
obtained.  Not  infrequently  cases  are  encountered  in  which  pain  is  most 
severe  over  the  great  trochanter  or  about  the  joint  itself,  indicating  an  in- 
tracapsular tension  due  to  an  abscess  or  exudate  within  the  capsule.  It  is 
important  that  recurring  pain  in  tuberculous  hips  should  not  be  considered 
as  the  so-called  acute  stage,"  but  as  evidence  of  tension,  usually  of  transient 
character.  In  this  type  of  case  it  is  difficult  to  offer  immediate  relief  by  any 
other  method  than  cutting,  but,  if  possible,  the  conservative  plan  should  be 
followed,  thus  preventing  an  open  tuberculous  wound.  Cast  changes  should 
be  made  every  two  or  three  months,  depending  on  the  progress  made  by  the 
patient.  Goldthwait^  has  reported  a  number  of  cases  in  which  he  has 
employed  the  combined  method  of  rest  and  fixation  with  activity  by  using 
crutches  and  no  weight-bearing  during  the  period  of  acute  pain.  In  several 
cases  I  have  been  compelled  to  resort  to  this  method,  but  always  with  re- 
luctance, for  I  firmly  believe  crutch  activity  to  be  quite  inferior  to  the  weight- 
bearing.  It  is  usually  a  safe  rule  to  be  guided  by  the  child's  instincts,  for 
he  will  not  walk  when  to  do  so  will  cause  pain. 

It  is  well  known  that  many  of  the  so-called  cold  or  tuberculous  abscesses 
disappear  without  operative  intervention,  depending  upon  the  general 
health  and  resistance  of  the  patient."  With  this  constantly  in  mind,  and 
knowing  the  chronicity  of  the  sinus,  it  has  been  my  rule  never  to  open  an 
abscess  of  this  type  unless  absolutely  necessary.  If,  however,  there  is  dan- 
ger of  rupture  or  by  pressure  it  causes  excruciating  pain,  incision  or  aspira- 
tion is  indicated.  After  opening  the  abscess,  its  cavity  is  thoroughly  cleansed 
by  dry  sterile  gauze,  and  the  skin  and  deeper  tissues  sutured  without  drain- 
age. The  principles  of  Treves'  operation*  for  psoas  abscess  can  be  applied 
to  any  tuberculous  abscess.  About  50  per  cent,  of  abscesses  so  treated  heal 
within  a  period  of  ten  days  or  two  weeks.  The  drainage  method  always 
tends  to  encourage  a  sinus,  and  should  not  be  used.*^  The  chronic  sinuses 
following  the  opening  or  rupture  of  abscesses  are  even  more  difficult  to  treat 
than  the  abscesses  themselves.  Beck^  has  recently  advocated  the  injec- 
tion of  a  bismuth-vaselin  and  later  a  bismuth-paraffin  preparation,  which 
has  shown  very  excellent  results.  Personal  experience  with  Beck's  bismuth 
paste  indicates  that  it  will  revolutionize  the  treatment  of  sinus  tracts.     In- 


WEIGHT-BEARING    AND    FIXATION   IN   HIP    DISEASE. — WILSON.  115 

stead  of  washing  them  with  various  solutions,  they  will  be  kept  dry.  Keep- 
ing the  tracts  wet  encourages  their  continuance,  aids  in  the  formation  of 
fungus-like  growth  lining  the  sides,  whereas,  if  the  moisture  can  be  excluded, 
rapid  closure  and  sound  healing  are  the  rule  in  all  cases  except  where  sequestra 
are  present.  It  is  not  an  unusual  occurrence  to  witness  the  closure,  "vvithin 
three  weeks,  of  sinuses  which  have  been  dribbling  pus  for  many  years. 
Beck's  method  deserves  recognition  as  one  of  the  most  important  additions 
to  the  rational  treatment  of  bone  tuberculosis. 


BIBLIOGRAPHY. 

1.  Adolph   Lorenz:    "Tlie  Final  Terminations  of  the  Treatment  of  Coxitis  and  the 

Simplest  Remedies."     Original  paper. 

2.  Emil  G.  Beck:    "Fistulous  Tracts,  Tuberculous  Sinuses,  and  Abscess  Cavities," 

Jour.  Amer.  Med.  Assoc,  March  14,  1908. 

3.  Leonard  W.  Ely:  "The  Treatment  of  Joint  Tuberculosis  in  Children,"  Med.  Rec, 

December,  1907. 

4.  John  Carling:  "Open-air  Treatment  of  Tuberculous  Bone  and  Joint  Diseases,"  New 

York  Med.  Jour.,  June  8,  1907. 

5.  John  D.  Adams:  "A  Report  of  Seventeen  Cases  in  Open-air  Treatment  for  Surgical 

Tuberculosis  in  Children,"  Boston  Med.  and  Surg.  Jour.,  January  18,  1906. 

6.  Adolph  Lorenz:  "The  Simplest  Mechanical  Method  of  Treating  Coxitis  and  Its  Re- 

sults," Amer.  Jour.  Orthop.  Surg.,  October,  1906,  p.  150. 

7.  J.  E.  Goldthwait:   "Treatment  of  Tuberculosis  of  the  Hip,"  Boston  Med.  and  Surg. 

Jour.,  February,  1907. 

8.  Treves:  "Manual  of  Operative  Surgery,"  edit.  1903,  vol.  ii,  p.  772. 

9.  H.  Augustus  Wilson:   "Modern  Tendencies  in  the  Treatment  of  Bone  Tuberculo- 

sis," Amer.  Med.,  November,  1907. 

10.  Ibid.:   "Outdoor  Life  versus  Confinement  in  the  Treatment  of  Bone  Tuberculo- 

sis," Penn.  Med.  Jour.,  January,  1906. 

11.  Ibid.:    "The  Chnical  Significance  of  the  So-called  Acute  State  of  Bone  Tubercu- 

losis," Penn.  Med.  Jour.,  July,  1907. 

12.  Ibid.:   "Tuberculous  Joint  Diseases,"  New  York  Med.  Jour.,  March,  1902. 

13.  Ibid.:  "Medico-legal  Aspect  of  Tuberculous  Joint  Disease,"  Amer.  Med.,  July,  1901. 

14.  Ibid.:  "Apparently  Unavoidable  Errors  in  the  Diagnosis  of  Psoas  Abscess,"  Amer. 

Med.,  vol.  X,  No.  2,  pp.  55-57. 

15.  Ibid.:  "Pus  in  the  Pelvis  as  a  Result  of  Bone  or  Joint  Necrosis;  Diagnosis  and 

Treatment,"  Amer.  Med.,  vol.  iv,  No.  23,  December,  1902. 


El  Tratamiento  per  Medio  de  la  Carga  de  Pesos  y  el  Fijamiento  al  Espigdn 
de  la  Cadera,  de  Lorenz. — (Wilson.) 

La  importancia  de  la  carga  de  pesos  se  ve  demostrada  en  los  efectos 
ben^ficos  de  la  vida  en  las  afueras.  La  actividad  constitucional  previene 
la  estasis  en  la  circulacion.  La  falta  de  uso  consecuente  al  confinamiento 
y  la  inactividad  favorece  la  atrofia.  La  carga  de  pesos  sin  fijamiento,  bajo 
condiciones  favorables,  puede  producir  la  recuperacion,  mas  con  anquilosis 
en  la  postura  deformada.  La  carga  de  pesos  con  el  espig6n  dc  la  cadera, 
recomendado  por  Lorenz,  facilita  la  vida  en  las  afueras  y  tambi^n  acorta  el 


116  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

tiempo  del  tratamiento.  Los  resultados  demuestran  una  funcion  normal 
completa  cuando  empleada  en  casos  apropiados.  Recuperacion  rapida  en 
algunos  casos  con  abscesos  y  en  otros  una  lenta,  mas  permanente,  recupera- 
cion. Inyecciones  del  bismuto  de  Beck  en  las  fistulas.  Profunda  anquil- 
osis  en  los  casos  previamente  guardados  en  la  cama  6  en  aquellos  en  los  cuales 
existe  una  atrofia  debida  a  la  falta  de  uso  producida  por  medio  del  uso  de 
muletas.  El  desarrollo  muscular  de  la  parte  atrofiada,  con  frecuencia  re- 
quiere  el  cambio  del  molde  lo  que  demuestra  los  efectos  benefices  del 
tratamiento.  La  carga  de  pesos  con  el  fijamiento  ayuda  en  el  procuramil- 
ento  de  los  efectos  beneficos  de  la  Hiperemia  de  Bier.  Tratamiento  con- 
stitucional,  dieta.  Dislocacion  patologica  puede  ocurrir  cuando  la  posicion 
del  fijamiento  es  inapropiada.  La  postura  mas  favorable  es  de  la  de  viente 
grados  de  flexion,  veinte  grados  de  abduccion  y  cinco  grades  de  una  rotacion 
external. 


Die  Behandlung  von  tuberculosen  Hiiftenerkrankungen  mit  Lastentragen, 
und  Fixation  mit  Lorenz'scher  Hiiften-Spica. — (Wilson.) 

Die  wohlthuende  Wirkung  des  Aufenthaltes  in  frischer  Luft  wird  durch 
das  Lastentragen  unterstiitzt.  Allgemeine  korperliche  Thatigkeit  verhin- 
dert  Stockungen  des  Blutkreislaufes.  Bettlagerigkeit  und  Unthatigkeit 
begiinstigen  Atropine  von  Nichtgebrauch.  Das  Lastentragen  ohne  Fixa- 
tion kann  unter  besonders  giinstigen  Umstanden  zwar  zur  Heilung  fiiliren, 
geht  aber  mit  Ankylose  in  entstellter  Lage  einher.  Das  Lastentragen  mit 
einer  Lorenz'schen  Hiiften-Spica  erleichtert  den  Aufenthalt  im  Freien  und 
kiirzt  die  Behandlungszeit  ab.  Wenn  in  geeigneten  Fallen  angewandt,  ist 
eine  normale  Funktion  die  Folge.  In  einigen  Fallen  von  Abscessbildungen 
findet  eine  Wiederherstellung  schnell  statt,  in  anderen  Fallen  geschieht 
die  Wiederherstellung  langsamer  aber  dauernd.  Uber  Beck's  Bismuthein- 
spritzungen  in  Fistelgangen.  Uber  gute  Ankylose  in  Fallen,  in  denen  Bett- 
lagerigkeit vorausgegangen  war,  oder  in  denen  die  Atrophic  von  Nichtge- 
brauch durch  Benutzung  von  Kriicken  hervorgebracht  wurde.  Entwicklung 
der  Muskulatur  an  einem  atrophirten  Beine  erfordert  oft  ein  haufigeres 
Wechseln  des  Gypsverbandes,  das  zeigt  aber  den  erreichten  guten  Erfolg  an. 
Das  Lastentragen  mit  gleichzeitiger  Fixation  wirkt  fordernd  auf  die  Er- 
reichung  giinstigerer  Einfliisse  von  der  Bier'schen  Hyperamie.  Uber  allge- 
meine Behandlung.  Uber  Diat.  Pathologische  Verrenkungen  konnen  durch 
unzweckmiissige  Lage  bei  der  Fixation  hervorgebracht  werden.  Die  am 
meisten  giinstige  Lage  ist  diejenige  von  zwanzig  Grad  Flexion,  zwanzig 
Grad  Abduction,  und  fiinf  Grad  Rotation  nach  aussen. 


VACCINE  THERAPY  IN  JOINT  TUBERCULOSIS. 
By  Edward  H.  Ochsner,  B.S.,  M.D., 

Attending  Surgeon  to   Augustana   Hospital:  Adjunct  Professor  of   Clinical    Surgery,   University  of 

Illinois,  Chicago. 


Before  taking  up  the  subject  of  vaccine  therapy  as  related  to  joint  tuber- 
culosis, I  wish  to  state  that  I  consider  it,  when  properly  controlled  by  reading 
the  opsonic  index,  a  very  valuable  adjunct  in  the  treatment  of  tubercular 
joints,  but  in  order  not  to  be  misunderstood,  I  wish  to  emphasize  that  there 
are  other  therapeutic  agents  which  are  quite  as  essential  to  the  successful 
treatment  of  this  affection  and  should  never  be  lost  sight  of  or  neglected. 
I  refer  to  proper  hygienic  conditions,  such  as  plenty  of  fresh  air,  sufficient 
suitable  food,  prevention  of  secondary  infection,  and  proper  immobiliza- 
tion. I  will,  however,  confine  myself  in  these  remarks  to  a  consideration  of 
the  influence  of  proper  immobilization  and  vaccine  therapy  upon  the  progress 
of  the  disease,  and  the  ultimate  functional  result,  with  special  reference  to 
the  mobility  of  the  joint. 

I  take  it  for  granted  that  this  audience  is  thoroughly  familiar  with  the 
principles  of  vaccine  therapy  as  taught  and  practised  by  Wright,  and  con- 
sequently will  not  go  into  this  detail  further  than  to  say  that,  while  I  agree 
with  the  critics  of  Wright  that  the  opsonic  index  cannot  be  determined  with 
absolute  accuracy,  I  believe  that  a  careful,  conscientious  laboratory  worker 
can  ascertain  such  variation  in  the  opsonic  index  as  is  essential  to  avoid  the 
administration  of  such  large  or  frequently  administered  doses  of  vaccine  as 
would  cause  too  great  a  depression  of  the  opsonic  index,  or  to  administer  a 
new  dose  during  a  pronounced  negative  phase.  This,  after  all,  I  consider 
the  most  important  reason  for  a  careful  reading  of  the  opsonic  index. 

If  patients  with  joint  tuberculosis  come  to  the  surgeon  sufficiently  early; 
if  they  are  placed  under  proper  hygienic  conditions;  if  suitable  measures  are 
adopted  for  the  prevention  of  secondary  infection;  if  the  joints  are  perfectly 
immobilized  for  a  sufficient  length  of  time,  and  if  vaccine  therapy  is  insti- 
tuted under  control  of  the  opsonic  index,  I  believe  that  the  great  majority 
of  cases  will  secure  perfect  or  nearly  perfect  functional  and  anatomic  re- 
sults. 

l\Iany  teachers  have  taught  and  are  still  teaching  that  long-continued 
immobilization  of  an  inflamed  joint   favors  ankylosis.     This  teaching  is 

117 


118  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

theoretically  untenable,  and  contrary  to  clinical  experience,  as  I  believe  we 
will  be  able  to  prove. 

Volkman  taught  us,  and  I  believe  correctly,  that  the  primary  lesion  in 
joint  tuberculosis  is  usually  located  in  the  bone,  and  that  in  the  majority 
of  cases  the  joint  involvement  is  secondary.  Clinically,  the  first  tiling  that 
is  usually  noted  is  a  moderate  degree  of  pain,  followed,  in  a  varying  period 
of  time,  by  an  effusion  into  the  joint  and  an  attempt  at  immobilization  of  the 
joint  by  the  surrounding  muscles.  The  two  signs,  effusion  and  rigidity, 
should  long  ago  have  taught  us  that  when  an  inflammatory  process  exists  in  a 
joint,  our  efforts  should  be  directed  toward  preventing  contact  and  friction 
between  the  opposing  articular  surfaces.  This  can  best  be  accomplished  by 
sufficiently  prolonged  absolute  immobilization  of  the  joint.  If  active  and 
passive  motion  are  permitted,  or,  as  is  sometimes  done,  even  encouraged, 
the  endothelial  coverings  of  the  joint  cartilages  are  very  apt  to  be  damaged. 
If  two  opposing  surfaces  become  thus  abraded,  we  are  almost  sure  to  have 
fibrous  ankylosis.  If  active  and  passive  motion  is  vigorous  enough  and  pro- 
longed enough,  the  cartilage  also  will  become  destroyed  in  places,  and  if 
opposing  surfaces  of  the  joint  cartilages  become  destroyed,  bony  ankylosis 
is  sure  to  follow.  Proper  immobilization  with  undisturbed  joint  effusion 
will  prevent  this  undesirable  termination  in  a  very  considerable  percentage 
of  cases,  especially  if  it  is  further  aided  by  vaccine  therapy. 

For  the  past  two  years  we  have  been  using  vaccine  treatment  as  a  routine 
procedure  in  all  our  cases  of  tuberculosis  for  whom  it  was  convenient  to 
remain  in  or  near  the  city,  and  rather  early  in  our  experience  it  seemed  to  me 
that  tubercular  cases  thus  treated  reacted  more  quickly,  and  in  joint  tuber- 
culosis it  appeared  that  when  the  last  cast  was  removed,  ankylosis  of  the 
joint  was  less  common  and  less  severe.  It  is,  of  course,  too  early  to  reach 
absolutely  definite  conclusions  on  this  point,  as  many  of  the  cases  are  still 
under  treatment,  and  the  final  findings  cannot  yet  be  recorded.  However, 
the  gi'eater  mobility  of  the  joints  was  sufficiently  pronounced  to  attract 
my  attention,  and  I  have  consequently  since  that  time  made  a  rather  criti- 
cal study  of  the  patients,  with  special  reference  to  this  point,  and  naturally  I 
tried  to  discover  what  the  reason  or  reasons  might  be  for  this  difference  in 
the  healing  process. 

About  this  time  I  had  three  very  interesting  cases  of  bilateral  tubercular 
cervical  adenitis.  In  each  case  I  did  a  radical  operation  on  one  side,  then 
placed  the  patient  on  vaccination  treatment  for  from  six  to  eight  weeks,  and 
then  operated  on  the  other  side.  In  each  case  I  noticed  the  following  facts: 
The  glands  first  operated  upon  had  their  ordinary  gland  capsule,  but  in  addi- 
tion a  very  considerable  deposit  of  pericapsular  connective  tissue,  the  vas- 
cularity of  the  parts  being  about  as  is  usually  fountl  in  these  cases.  When 
operating  the  second  time,  quite  a  different  condition  was  found.    While 


VACCINE   THERAPY    IN   JOINT   TUBERCULOSIS. — OCHSNER.  119 

the  gland  capsule  was  about  the  same  as  at  the  first  operation,  the  peri- 
glandular connective  tissue  had  almost  entirely  disappeared,  the  glands  were 
very  much  more  freely  movable,  and  the  surrounding  tissues  were  much  more 
vascular  than  they  had  been  at  the  previous  operation — so  vascular,  in  fact, 
that  there  was  general  capillary  bleeding  mth  every  cut  of  the  knife  or  snip 
of  the  scissors,  interfering  very  seriously  with  rapid  cUssection.  I  have 
since  observed  the  same  condition  twice,  in  fact,  in  all  cases,  five  in  number, 
in  which  there  has  been  a  considerable  interval  of  vaccine  treatment  between 
the  first  and  second  operation. 

If  the  above  observation  is  correct,  and  if  it  will  be  substantiated  by 
future  cases  and  other  observers,  it  will  explain  why  there  is  less  ankylosis 
in  cases  of  joint  tuberculosis  treated  with  vaccination  than  is  the  case  if 
treated  by  the  ordinary  method.  We  have  long  been  taught  that  tubercu- 
losis is  cured  by  a  process  of  exclusion,  because  this  is  the  process  we  have 
been  able  to  observe  and  follow  as  healing  has  progressed.  So  far  as  I  know, 
other  methods  of  healing  have  not  been  recognized,  and  yet  it  seems  more 
than  probable  that  there  are  other  methods,  for  in  the  perfect  healing  out  of 
a  tubercular  peritonitis  it  is  hard  to  conceive  that  it  has  all  been  a  process  of 
exclusion  and  sclerosis.  To  further  substantiate  this  view  I  might  cite  two 
cases  of  tubercular  cervical  adenitis  which  had  received  no  vaccination 
treatment,  in  which  there  was  little  or  no  periglandular  connective  tissue 
found  at  the  operation. 

The  healing  process  of  tuberculosis  is  usually  described  as  a  proliferation 
of  fixed  tissue  cells,  which  later  develop  into  mature  connective  tissue, 
which,  in  contracting,  slowly  constrict  and  ultimately  obliterate  all  the 
blood-vessels,  resulting  in  fatty  degeneration,  then  in  necrosis,  and  finally 
ending  in  calcareous  deposits.  In  other  words,  the  tubercular  process  is 
walled  in  and  the  tubercle  bacilli  starved. 

The  process  of  healing,  which  we  believe  we  have  observed  here,  is  evi- 
dently entirely  different:  it  is  fundamentally  a  phagocytic  process,  a  pro- 
cess of  vascularization  instead  of  sclerosis;  it  is  a  tearing  down  of  the  con- 
nective-tissue wall,  giving  the  phagocytes  an  opportunity  to  destroy  the 
tubercle  bacilli.  The  two  processes  may  be  likened  to  the  two  recognized 
methods  of  warfare — one  a  siege  with  the  cutting  off  of  supplies  and  pro- 
visions and  the  ultimate  starvation  of  the  garrison,  and  the  other  the  de- 
struction of  the  walls  of  the  fortress  with  heavy  artillery,  with  a  final  charge 
and  a  hand-to-hand  combat  with  the  garrison. 

I  do  not  wish  to  consume  your  time  with  a  detailed  report  of  the  cases 
thus  treated,  nor  even  with  a  statistical  summary,  but  will  briefly  give  the 
history  of  two  cases,  one  a  simple  tuberculosis  of  the  knee,  the  other  a  tuber- 
culosis of  the  knee  complicated  by  mixed  infection.  In  this  way  I  hope  to 
be  able  to  emphasize  and  elucidate  some  of  the  points  above  brought  out. 


120  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

H.  H.,  male,  aged  seventeen,  tailor.  First  placed  himself  under  my  care 
May  11,  1907,  with  a  history  of  having  been  well  to  the  age  of  fourteen,  when 
he  fell,  injuring  right  knee,  experiencing  slight  pain,  but  had  no  further 
trouble  until  four  months  later,  when  knee  became  swollen,  painful,  and 
motion  restricted.  Shortly  after  knee  was  aspirated,  injected,  and  appar- 
ently rather  ineffective  attempts  made  to  immobihze  same.  Later  again 
injected;  finally  put  on  Bier's  treatment.  When  first  seen  by  me,  general 
nutrition  fair,  weight,  145  pounds,  exaixdnation  negative  except  that  right 
knee  was  greatly  swollen,  boggy,  extremely  painful  on  slightest  passive 
motion,  active  motion  impossible,  held  rigid  at  an  angle  of  about  140  de- 
grees, unable  to  bear  weight,  temperature  varying  during  the  course  of  the 
next  week  between  98f°  and  100f°;  pulse  between  80  and  120;  opsonic  index, 
0.6.  As  it  was  impossible  to  straighten  the  knee,  the  patient  was  anesthe- 
tized, the  knee  placed  at  an  angle  of  175  degrees,  plaster-of-Paris  cast  ap- 
plied from  the  malleoli  to  the  tuber  ischium,  and  vaccination  treatment  in- 
stituted. After  a  few  days  patient  was  allowed  to  get  up;  cast  was  left  in 
place  for  four  months,  at  the  end  of  which  time  the  patient  had  gained  so 
much  in  weight  that  the  cast  had  to  be  changed.  The  second  cast  was  left 
in  place  eleven  months.  When  this  was  removed,  patient's  general  health 
was  excellent;  weight,  177  pounds.  On  inspection,  knee  perfectly  normal, 
straight,  active  motion  about  20  degrees,  passive  motion  30  degrees,  op- 
sonic index  during  the  last  year  having  varied  between  1.1  and  1.7. 

J.  B.,  male,  aged  thirty-four,  blacksmith.  Came  under  my  care  on  the 
21st  of  May,  1907.  The  essential  points  of  his  history  are  that,  twenty- 
eight  months  previously,  after  an  illness  described  by  him  as  la  grippe,  both 
lower  extremities  from  the  kness  down  to  the  toes  became  swollen.  After 
the  swelhng  subsided  the  patient  noticed  that  the  right  leg  could  not  be 
fully  extended.  This  limitation  of  motion  had  persisted  ever  since.  Fifteen 
months  Vjefore  his  admission  a  swelling  developed  on  the  outer  side,  a  little 
below  the  right  knee.  Eleven  months  before  admission  this  abscess  was 
incised  and  drained;  three  months  later  this  was  done  again;  drainage  con- 
tinued for  three  months  and  intermittently  from  that  date  until  the  day  of 
admission.  On  admission  the  patient  was  found  considerably  emaciated, 
the  right  knee  was  markedly  swollen,  slightly  flexed,  rigid,  but  not  com- 
pletely anlsylosed;  active  motion  impossible;  slightest  attempt  at  passive 
motion  caused  excruciating  pain;  leg  and  foot  swollen;  drop  anlde;  several 
sinuses  discharging  pus.  Temperature  during  the  succeeding  weeks  varied 
between  97|°  and  104°  F.;  pulse,  66  to  128;  opsonic  index  on  admission,  0.6. 
The  patient  was  anesthetized,  the  right  lower  extremity  immobilized  in  a 
fenestrated  plaster-of-Paris  cast,  with  the  knee  at  an  angle  of  175  degrees  and 
the  ankle  at  85  degrees;  patient  put  to  bed  and  vaccination  treatment  in- 
stituted. As  soon  as  the  extreme  tenderness  subsided,  he  was  allowed  to 
sit  up,  later  to  walk  with  crutches  with  a  high  sole  under  the  good  foot,  and 
finally,  when  the  tenderness  in  the  knee-joint  had  entirely  disappeared,  he 
was  allowed  to  walk  with  ordinary  shoes  and  a  cane.  The  patient  rapidly 
gained  in  weight  and  strength,  his  temperature  and  pulse  became  normal, 
and  when  the  last  cast  was  removed  on  August  20,  1908,  the  right  lower  ex- 
tremity, except  for  some  atrophy  of  the  muscles,  made  a  practically  norrnal 
appearance,  the  sinuses  being  entirely  healed,  and  about  30  degrees  passive 
motion  being  possible  without  the  slightest  pain  or  discomfort. 


VACaNE   THERAPY   IN    JOINT   TUBERCULOSIS. — OCHSNER.  121 

I  feel  sure  that  you  will  agree  with  me,  even  from  these  short  histories, 
that  here  we  had  two  very  unfavorable  cases,  and  that  the  results  are  cer- 
tainly most  satisfactory.  If  these  were  the  only  cases  thus  treated,  they 
would  prove  very  little,  but  we  have  had  quite  a  series  of  similar  cases  in- 
volving practically  every  joint  of  the  extremities  in  which  we  have  secured 
similar  gratifying  results. 

In  conclusion  I  wish  to  state  that  I  am  very  well  aware  of  the  fact  that  a 
relatively  small  number  of  cases  covering  a  short  period  of  time  cannot  fur- 
nish conclusive  evidence,  but  the  experience  we  have  had  thus  far  has 
been  so  uniform  that  I  deemed  it  of  sufficient  importance  to  report  thus 
briefly. 

Up  to  a  few  years  ago  we  were  very  well  satisfied  if  we  were  able  to  bring 
a  case  of  simple  tubercular  arthritis  to  a  successful  healing  of  the  tubercular 
process  without  surgical  intervention,  and  we  w^ere  quite  satisfied  if  we  ac- 
complished this  result  with  ankylosis,  providing  the  limb  was  ankylosed  in  a 
useful  position.  A  larger  joint  with  mixed  infection  sometimes  resulted  in 
the  death  of  the  patient,  often  in  the  loss  of  the  limb,  and  very  commonly 
in  persisting  sinuses.  I  believe  that  now  we  can  practically  always  save  the 
life  and  limb  of  such  a  patient,  and  sometimes,  as  in  the  last  case  above 
cited,  even  secure  a  useful  joint.  In  tubercular  joints  uncomplicated  with 
mixed  infection  we  can,  if  the  patients  come  to  us  sufficiently  early,  secure 
perfect  functional  and  anatomical  results  in  the  great  majority  of  cases. 


Vacciua-terapia  en  la  Tuberculosis  de  las  Articulaciones. — (Ochsxer.) 
La  vaccina-terapia  en  la  tuberculosis  de  las  articulaciones,  nunca  debera 
ser  empleada  sino  en  conexion  con  una  cuidadosa  observacion  del  index 
opsonico,  y  tambien  esta  debera  ser  asociada  con  los  otros  procedimientos 
reconocidos  en  el  tratamiento  de  la  tuberculosis  en  general,  tales  como  el 
aire  puro,  alimentacion  apropiada,  inmobilizacion  de  la  articulacion  afectada, 
prevencion  de  una  infeccion  secundaria,  etc.  Con  este  procedimiento  se 
obtiene  un  por  ciento  conciderable  de  una  cura  perfecta,  anatomica  y  func- 
ional,  por  que  el  tratamiento  de  la  vaccina  produce  una  cura  con  la  minima 
producion  de  tejido  conjuntivo. 


Th^rapie  vaccinale  dans  la  tuberculose  articulaire. — (Ochsner.) 
La  th6rapie  vaccinale  ne  doit  jamais  etre  employee  dans  la  tuberculose 
articulaire  qu'apres  une  controle  soigneuse  de  I'index  opsonique  et  en  con- 
comitance avec  d'autres  mdthodes  approuv4es  de  traitement,  telles  que  la 


122  SIXTH    INTERNATIONAL   CONGRESS    ON   TUBERCULOSIS. 

cure  d'air,  une  alimentation  appropriee,  I'immobilisation  de  I'articulation, 
le  traitement  preventif  de  I'infection  secondaire,  etc. 

Ainsi  employee,  elle  permet  d'obtenir  un  nombre  considerable  de  par- 
faites  guerisons  anatomiques  et  fonctionnelles,  parce  que  le  traitement 
vaccinal  produit  une  cure  radicale  avec  la  moindre  formation  de  tissu  con- 
jonctif. 


Vaccine-Behandlung  bei  Gelenks-Tuberkulose. — (Ochsner.) 
Vaccine-Behandlung  sollte  bei  Gelenks-Tuberkulose  nie  ohne  sorg- 
faltige  Beachtung  des  opsonischen  Indicis  unternommen  und  stets  in  Ge- 
meinschaft  mit  den  iibrigen  anerkannten  Behandlungsmethoden,  als  frische 
Luft,  angemessene  Ernahrung,  Fixation  des  Gelenkes,  Verhinderung  einer 
sekundaren  Infektion,  etc.,  ausgefiihrt  werden. 

In  dieser  Weise  ist  ein  sehr  ansehnlicher  Prozentsatz  anatomischer  und 
funktioneller  Heilungen  zu  erzielen,  da  die  Bindegewebs-Formation  beim 
Heilungsprozesse  nach  Behandlung  mit  Vaccine  eine  minimale  ist. 


DISCUSSION. 
Eugene  Caravia,  M.  D.  (New  York)  said:    Dr.  Cuguillere's  vegetable 
serum  is  in  the  ninth  year  of  its  existence.     Its  principle  is  based  on  Koch's 
writings,  who,  in  order  to  conquer  tuberculosis,  set  himself  the  task  of  solv- 
ing three  propositions : 

1.  To  determine  and  cultivate  the  pathogenic  agent  of  tuberculosis. 

2.  To  find  out  and  classify  all  the  agents  able  to  attenuate  its  culture 
or  kill  it  in  vitro. 

3.  To  find  out  a  way  to  obtain  the  same  effects  in  the  animal  and  human 
organism. 

Everybody  knows  how  successful  he  has  been  in  the  first  proposition  by 
determining  the  staining  reaction  and  cultivating  the  bacillus  known  by  his 
name.  To  solve  the  second  and  third  propositions  Koch  used  successfully, 
but  in  vitro  only,  physical  (heat,  light,  electricity)  and  chemical  (acid  bases) 
agents.     But  those  agents  could  not  be  used  in  living  beings. 

Another  line  of  experimentation  brought  Professor  Koch  to  use  a  certain 
number  of  metals  which  have  the  power  to  kill  rapidly  and  surely  the  cul- 
tures of  Bacillus  tuberculosis. 

Rollin  found  that  a  non-oxidizable  metal  without  radio-activity,  like 
platinum  in  metal  state,  will  totally  prevent  development  of  Aspergillus 
niger.  Koch  has  found  that  cultures  of  Bacillus  tuberculosis  are  killed  in 
presence  of  even  an  infinitesimal  solution  of  the  salts  of  gold.     Other  metals 


VACCINE    THERAPY    IN    JOINT   TUBERCULOSIS. — OCHSNER.  123 

exhibit  the  same  properties.  Metalloids,  like  sulphur,  chlorid,  iodin,  bro- 
min,  are  as  active,  if  not  more  so. 

But  those  agents  have  been  found  without  action  on  the  bacillus  in 
living  organisms.  "A  healthy  organism,"  says  Dr.  Cuguillere,  "tolerates  the 
absorption  of  metallic  salts  only  with  difficulty.  An  organism  infected  with 
tuberculosis  is  not  able  to  retain  those  necessary  for  its  own  defense.  It 
demineralizes  itself,  and,  consequently,  it  seems  impossible  to  assimilate 
new  ones." 

Then  Professor  Koch  abandoned  this  line  of  investigation  and  declared 
that  tuberculosis  would  be  curable  by  the  introduction,  into  the  organism, 
of  a  remedy  equally  organic,  hence  his  new  researches  on  products  elabo- 
rated by  the  Bacillus  tuberculosis. 

Dr.  Cuguillere  agrees  with  the  opinion  that  tuberculosis  can  be  cured  by 
a  living  serum.  But  he  thinks  that,  instead  of  toxins  and  antitoxins,  this 
serum  could  be  made  to  carry  colloidal  metals  already  assimilated,  which  are 
organic  and  living,  and  are  possessed  of  their  maximum  activity.  Conse- 
quently it  is  the  mineral  and  vegetable  kingdom  that  furnishes  the  active 
principle  of  his  serum — that  is,  organic  sulphur  taken  from  fresh  juices  of 
brassica,  allium,  water-cress,  horseradish,  and  other  herbs  known  and  for 
many  years  used  as  antiscorbutic  and  antirachitic  remedies. 

Dr.  Cuguillere's  serum  is  a  yellow  liquid  having  a  strong  odor  of  garlic. 
It  produces  a  burning  sensation,  which  disappears  a  few  minutes  after  the 
injection.  It  is  not  toxic.  One  hypodermic  injection  of  from  2  to  5  c.c. 
is  given  every  week. 

The  formula,  as  given  at  the  Congress  of  Tuberculosis  in  Paris,  is: 

Allylum  sulphide* 1  gram. 

Tinct.  of  myrrh 1  gram. 

Hayem's  glycerinated  serum 100  grams. 

Cuguillere,  in  a  paper  read  before  the  International  Congress  of  Medicine 
held  in  Biarritz,  April,  1903,  presented  the  history  of  several  cases  of  cox- 
algia,  osteo-arthritis  of  the  foot-  and  knee-joints,  with  or  without  fungosities 
and  suppuration,  osteo-periostitis  of  the  tibia,  caries  of  the  ribs,  pleural 
tuberculosis,  adenitis  of  the  neck,  tuberculous  tumors  of  the  breast,  lupus, 
peritonitis,  and  salpingo-ovaritis. 

Dr.  Cuvelier,  of  Lens  (Belgium),  at  the  International  Congress  of  Tuber- 
culosis held  in  Paris  in  1905,  presented  the  history  of  2  cases  of  coxalgia, 
2  cases  of  white  swelling  of  the  knee,  1  of  the  wi-ist,  and  one  of  the  elbow. 

I  have  treated  2  cases  of  adenitis  of  the  neck,  1  small  subcutaneous  tumor 

of  the  breast,  1  white  swelling  of  the  knee,  and  1  of  periostitis  of  the  tibia. 

This  last  one  developed  two  months  after  the  removal  of  the  right  testicle 

for  tuberculosis.     In  all  these,  as  well  as  in  numerous  other  cases,  no  other 

*  The  synthetic  allylum  sulphide  is  inactive. 


124  SIXTH    INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

treatment  has  been  used  except  Cuguillere's  serum  in  weekly  injections. 
From  3  to  12  subcutaneous  injections  were  needed  to  bring  about  a  recovery 
which  was  permanent,  since  months  and  years  after  cessation  of  the  treat- 
ment there  has  been  no  relapse  and  no  tuberculous  manifestations  in  any 
part  of  the  body.  By  the  use  of  Cuguillere's  vegetable  serum  alone  ab- 
normal temperature,  high  or  low,  becomes  normal,  appetite  returns  or  in- 
creases, pain  stops,  swellings  disappear,  suppuration  dries  up,  fungosities 
are  resorbed,  the  movements  of  the  articulations  involved  are  preserved. 
The  healing  takes  place  by  the  fibroplastic  process  and  by  segmentation  and 
gradual  ingestion  of  Koch's  bacilli  by  the  leukocytes. 

Except  in  cases  of  tuberculosis  of  the  vertebrae  immobilization  is  not  re- 
quired. Instead,  moderate  exercise  and  massage  are  recommended,  and  no 
matter  how  critical  one  may  be,  he  cannot  help,  after  testing  Cuguillere's 
vegetable  serum,  but  find  that  in  surgical  tuberculosis  he  will  never  need 
the  knife,  except,  perhaps,  when  a  necrosed  bone  has  to  be  removed. 

Dr.  De  Forest  Willard  (Philadelphia)  thought  the  results  obtained 
by  Dr.  Wilson,  if  carefully  analyzed,  were  about  the  same  as  from  other 
methods  of  treatment.  If  we  could  secure  these  cases  early,  there  was  no 
question  but  what  all  of  us  could  secure  good  results.  Fresh  air  and  out- 
door life  were  very  important.  The  ambulatory  treatment  should  not  be 
used  in  the  acute  stage.  Vaccine  therapy  and  the  Bier  treatment  were  good, 
but  no  one  thing  would  cure  tuberculosis.  The  same  applied  to  injections. 
We  could  do  more  in  conquering  tuberculosis  by  building  up  the  resistance 
of  the  individual  than  by  attempting  to  destroy  tubercle  baciUi. 

Dr.  Russell  Bellamy  (Wilmington,  N.  C.)  believed  climate  was  the 
most  important  factor  in  dealing  with  these  cases.  Seven-eighths  of  all  the 
patients  in  the  Hospital  for  Deformities  in  New  York  were  from  the  slums 
of  New  York.     He  had  seen  splendid  results  from  the  use  of  the  plaster  spica. 

Dr.  Emil  G.  Beck  (Chicago)  said  he  would  hesitate  to  use  a  needle  where 
it  was  possible  to  inject  iodoform  or  bismuth  material  into  a  vein,  because 
death  would  follow  in  two  minutes.  He  had  proved  this  in  experiments  on 
guinea-pigs.  He  advocated  the  injection  with  a  glass  syringe  of  the  bismuth 
paste  after  opening  the  abscesses. 

Dr.  a.  T.  Cabot  (Boston)  wished  to  call  attention  to  one  point  in  the 
handUng  of  surgical  tuberculous  cases.  Patients  suffering  from  pulmonary 
tuberculosis  were  required  to  exercise  care  in  the  disposal  of  their  sputum, 
but  practically  no  attention  was  paid  in  hospitals  or  elsewhere  to  the  dis- 
posal of  surgical  dressings  from  tu]:)erculous  cases.  Such  dressings  should 
be  immediately  treated  with  boiling  water,  some  suitable  antiseptic,  or 
burned. 

Dr.  Tunstall  Taylor  (Baltimore)  said  weight-bearing  should  not  be 
used  in  acute  cases,  and  should  be  confined  to  hospital  and  sanatorium  treat- 


VACCINE   THERAPY   IN   JOINT   TUBERCULOSIS. — OCHSNER.  125 

ment,  as  it  was  sure  to  be  meddled  with  if  tried  at  home.  The  bivalve  spica 
was  best,  because  it  would  permit  massage.  Climatic  treatment  was  veiy 
important.  Vaccine  therapy  was  also  very  useful.  Braces  and  the  pro- 
longed use  of  traction  had  been  very  much  overdone.  On  the  other  hand, 
he  did  not  agree  with  Lorenz  that  early  ank^dosis  in  these  cases  was  desirable. 

Dr.  Wilson,  in  closing,  said  the  museums  were  full  of  specimens 
showing  joint  destruction  from  tuberculosis.  A  movable  and  functionating 
joint  was  always  preferable  when  such  function  was  not  apt  to  be  destruc- 
tive to  the  surrounding  tissues  and  to  the  health  of  the  patient.  But  where 
there  was  great  destruction  the  question  came  up  as  to  whether  it  was  better 
to  have  mobility  or  ankylosis,  he  was  unable  to  answer  the  question. 

Dr.  Ochsner,  in  closing,  said  he  wished  it  understood  that  vaccine 
therapy  was  not  a  cure-all;  it  was  only  a  very  valuable  adjunct  to  the  ordi- 
nary^ modes  of  treatment.  He  wished  to  lay  special  stress  upon  his  observa- 
tion that,  by  the  proper  application  of  vaccine  therapy,  he  had  been  able 
to  reduce  the  quantity  of  connective  tissue  in  the  healing  of  tuberculosis. 
He  was  sure  that  vaccine  treatment  would  reduce  the  mortality  somewhat. 
He  was  sure  that,  within  the  last  two  years,  he  had  had  several  cases  of 
joint  tuberculosis  which  came  with  great  sinus  formations  and  secondaiy 
infection  who  would  have  died  had  they  come  five  years  earlier  before  the 
use  of  the  vaccines.  He  firmly  believed  that  morbidity  would  also  be  re- 
duced by  vaccine  therapy  in  conjunction  with  other  measures. 


DEUX   FORMES   PARTICULIERES    D'ARTHROPATHIES 
TUBERCULEUSES  DU  GENOU. 

Par  le  Dr.  Mauclaire, 

Agr^g^  h  la  Faculty  de  M^decine  de  Paris. 


J'en  ai  vue  ici  deux  varietes  anatoraiques;  dans  la  premiere  il  s'agit  d'un 
^panchement  a  grains  riziformes,  dans  la  deuxieme  il  s'agit  d'un  epanche- 
ment  gelatin^forme. 

(a)  L'arthrite  a  grains  riziformes  a  ete  observe  chez  une  jeune  femme  de 
29  ans,  de  tres  forte  constitution,  n'ayant  aucune  trace  de  tuberculose  pul- 
monaire.  L'affection  debuta  en  Janvier,  1907,  et  j'examinai  la  malade 
trois  mois  apres.  Elle  presentait  tous  les  signes  d'une  hydrarthrose,  mais  k 
la  pression  on  sentait  la  crepitation  caract^ristique.  Je  fis  I'arthrotomie 
externe,  I'^vacuation  de  I'^panchement  et  le  lavage  phenique.  La  malade 
a  gueri  rapidement  et  porta  une  genouillere.  Elle  reprit  une  profession 
tr^s  active  I'obligeant  a  marcher  beaucoup.  Je  la  revois  tous  les  trois  mois 
et  aujourd'hui  15  mois  apres  I'op^ration  il  n'y  a  aucune  recidive  locale,  ni 
trace  de  tuberculose  dans  une  autre  part  de  I'economie. 

Certes  des  observations  semblables  ne  sont  pas  rares;  toutefois  ce  qui 
est  interessant  dans  mon  observation  est  la  b^nignite  des  suites  operatoires 
et  la  persistance  de  la  guerison;  la  plupart  des  arthrites  h  grains  riziformes 
evoluant  vers  la  synovite  fongueuse.  II  s'agit  done  en  somme  d'une  tuber- 
culose articulaire  att^nuee. 

(6)  L'arthrite  h  epanchement  gelatineforme  du  genou  a  et^  observ^e 
chez  une  jeune  femme  de  32  ans,  Les  symptomes  etaient  ceux  d'une  tumeur- 
blanche  typique.  Apres  I'incision  pour  faire  une  resection,  je  fus  surpris 
de  trouver  dans  I'articulation  un  epanchement  gelatineforme  assez  abondant. 
Les  surfaces  articulaires  elles  memes  etaient  peu  l^sees.  II  y  avait  quelque 
fongosit^  articulaire  et  une  osteite  tuberculeuse  de  la  tete  du  genou. 

Je  fis  la  resection  du  genou.  La  consolidation  fut  longue  a  obtenir,  le 
membre  due  etre  immobilis^  pendant  4  mois. 

Get  aspect  gelatineforme  des  epanchements  tuberculeux  est  tres  rare. 
Je  I'ai  observe  cependant  dans  un  cas  de  peritonite  tuberculeuse  chez  une 
jeune  fille.  Dans  la  region  iliaque  gauche  et  dans  I'hypochondre  il  y  avait 
une  masse  gelatineuse  et  dans  le  reste  de  I'abdomen  il  y  avait  des  granula- 
tions tuberculeuse  sur  tout  le  peritoine. 

On  salt  que  pour  quelques  auteurs,  la  tuberculose  des  bourses  s4reuses 

126 


TWO   FORMS   OF   KNEE-JOINT  TUBERCULOSIS. — MAUCLAIRE.  127 

prearticulaires  se  presente  parfois  sous  cet  aspect  gelatineux  et  bien  des 
kystes  du  creux  poplite  seraient  de  nature  tuberculeuse. 


Zwie  besondere  Formen   von   tuberkuloser  Arthropathie   des   Kniees. — 

(Mauclaire.) 

Ich  habe  hier  zwei  anatomische  Varietaten  gesehen,  in  der  ersten  ist 
eine,  Reiskorper  enthaltende  Effusion;  in  der  zweiten  eine  gelatinose  Effu- 
sion. 

(a)  Arthritis  mit  R.eiskorpern  war  beobachtet  worden  bei  einer  jungen 
29  Jahre  alten  Frau,  von  sehr  starker  Konstitution,  mit  keinen  Zeichen 
von  Lungentuberkulose.  Die  Krankheit  begann  im  Januar,  1907,  und 
drei  Monate  spater  untersuchte  ich  die  Patientin.  Sie  zeigte  alle  Zeichen 
einer  Hydrarthrosis,  aber  auf  Druck  wurde  die  charakterische  Crepitation 
hervorgerufen.  Ich  nahm  eine  externe  Arthrotomie  vor,  welcher  Entleer- 
ung  der  Effusion  und  antiseptische  Reinigung  folgte.  Die  Patientin  erholte 
sich  rasch  und  trug  eine  Kniekappe.  Sie  besitzt  einen  sehr  lebhaften  Beruf, 
welcher  sie  veranlasst,  sehr  viel  zu  gehen.  Ich  habe  sie  alle  drei  Monate 
gesehen,  und  heute,  fiinfzehn  Monate  nach  der  Operation,  ist  keine  ortliche 
Zuriickkehr,  noch  ein  Auftreten  von  Tuberkulose  in  irgend  einem  anderen 
Telle  des  Korpers  aufgetreten. 

Es  ist  wahr,  dass  ahnliche  Falle  nicht  selten  sind.  Der  interessante 
Punkt  an  meinem  Falle  ist  die  Abwesenheit  unangenehmer  postoperativer 
Wirkungen  und  die  Bestandigkeit  der  Heilung,  da  die  meisten  Falle  von 
Arthritis  von  Reiskorpern  eine  Tendenz  zu  fungoser  Synovitis  zeigen. 
Der  Fall  ist  daher  einer  von  verringerter  tuberkuloser  Arthritis. 

(6)  Arthritis  mit  gelatinoser  Effusion  des  Kniees,  war  bei  einer  jmigen, 
32  Jahre  alten  Frau  beobachtet  worden.  Die  Symptome  waren  jene  einer 
typischen  weissen  Geschwulst,  nachdem  die  Incision  fiir  eine  Resection 
gemacht  worden  war,  war  ich  iiberrascht  in  dem  Gelenke  eine  beinahe 
reichliche  gelatinose  Effusion  vorzufinden.  Die  Gelenksflachen  selbst 
waren  sehr  wenig  angegriffen.  Es  waren  einige  fungose  Veranderungen 
im  Gelenke  vorhanden,  und  eine  tuberkulose  Osteitis  der  Patella. 

Ich  nahm  eine  Resection  des  Kniees  vor.  Die  Verbindung  war  unter- 
brochen,  und  das  Glied  hatte  durch  vier  Monate  hindurch  unbeweglich 
zu  sein. 

Dieser  gelatinose  Anblick  tuberkuloser  Effusion  ist  sehr  ungewohnlich. 
Nichtsdestoweniger  beobachtete  ich  ihn  in  einem  Falle  von  tuberkuloser 
Peritonitis  bei  einem  jungen  Madchen.  In  der  linken  Darmbeingegend  und 
im  Hypochondrium  war  eine  gelatinose  Masse  und  im  iibrigen  Teil  des 
Abdomens  waren  tuberkulose  Granulationen  iiber  das  ganze  Peritoneum 
verstreut. 


128  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

Nach  einigen  Autoren  offenbart  Tuberkulose  der  Gelenkschleimbeutel 
diese  gelatinose  F^rscheinung.  Und  viele  Cysten  des  Kniegelenkes  und 
namentlich  der  Regio  poplitea  werden  als  tuberkulos  angesehen. 


Two  Special  Forms  of   Tuberculous  Arthropathy  of  the  Knee. — 

(Mauclaire.) 

I  have  seen  here  two  anatomical  varieties.  In  the  first  there  is  an 
effusion  containing  rice  bodies,  in  the  second,  a  gelatinous  effusion. 

(a)  Arthritis  with  rice  bodies  was  observed  in  a  young  woman  twenty- 
nine  years  old,  of  very  strong  constitution,  with  no  trace  of  pulmonary 
tuberculosis.  The  illness  began  in  January,  1907,  and  I  examined  the 
patient  thi-ee  months  later.  She  showed  all  the  signs  of  a  hydrarthrosis, 
but  with  pressure  the  characteristic  crepitation  was  ehcited.  I  performed 
external  arthrotomy  followed  by  evacuation  of  the  effusion  and  anti- 
septic cleansing.  The  patient  recovered  rapidly  and  wore  a  knee-cap.  She 
resumed  a  very  active  profession,  which  obliges  her  to  walk  a  great  deal. 
I  see  her  every  three  months,  and  to-day,  fifteen  months  after  the  operation, 
there  is  no  local  recurrence  nor  trace  of  tuberculosis  in  any  other  part  of 
the  body. 

It  is  true  that  similar  cases  are  not  rare.  The  interesting  points  about 
my  case  are  the  absence  of  unpleasant  postoperative  effects  and  the 
permanence  of  the  cure,  most  cases  of  arthritis  with  rice  bodies  showing 
a  tendency  to  fungous  S5movitis.  The  case  is,  therefore,  one  of  attenuated 
tuberculous  arthritis. 

(6)  Arthritis  with  gelatinous  effusion  of  the  knee  was  observed  in  a 
young  woman  thirty-two  years  old.  The  symptoms  were  those  of  a  typical 
white  swelUng.  After  making  the  incision  for  a  resection,  I  was  surprised 
to  find  in  the  joint  a  rather  abundant  gelatinous  effusion.  The  articular 
surfaces  themselves  were  but  little  injured.  There  were  some  fungous 
changes  in  the  joint  and  a  tuberculous  osteitis  of  the  patella. 

I  did  a  resection  of  the  knee.  Union  was  delayed  and  the  limb  had  to 
be  immobilized  for  four  months. 

This  gelatinous  aspect  of  tuberculous  effusions  is  very  unusual.  Never- 
theless, I  observed  it  in  a  case  of  tuberculous  peritonitis  in  a  young  girl. 
In  the  left  iliac  region  and  hypochondrium  there  was  a  gelatinous  mass, 
and  in  the  rest  of  the  abdomen  tuberculous  granidations  scattered  over 
the  entire  peritoneum. 

According  to  some  wiiters,  tuberculosis  of  the  prearticular  serous 
bursse  presents  this  gelatinous  aspect,  and  many  cysts  of  the  pophteal 
space  are  regarded  as  tuberculous. 


IMMOBILIZATION  IN  TUBERCULOUS  ARTHRITIS. 

By  Dr.  A.  Codivilla, 

Bologna. 


In  the  treatment  of  tuberculosis  of  the  joints,  as  in  that  of  spondyUtis, 
the  difference  in  opinion  among  surgeons  consists  more  in  the  details  than  in 
the  essentials  of  the  treatment.  They  all  agree  in  admitting  that  our  inter- 
vention acts  indirectly,  even  when  it  is  operative,  and  that  the  healing  of  the 
process  is  due  to  the  good  organic  powers  of  resistance  against  the  local 
affection.  Therefore,  surgeons  try  to  remove  all  those  conditions,  both 
local  and  general,  which  tend  to  lower  the  vitality  of  the  organism,  and  to 
procure  those  which  may  strengthen  it  in  the  struggle ;  for  instance,  hygienic 
conditions,  sea  air,  immobility  of  the  affected  parts,  iodic  cure,  hyperemia 
(Bier),  emptying  of  abscesses,  endoarticular  and  para-articular  (sclerogenic) 
injections.  Thus  it  is  evident  that  the  surgeon's  aim  is  to  assist  nature  in 
the  normal  process  of  cure  of  the  local  tuberculosis.  But  the  same  thing 
must  be  admitted  when  the  surgeon  operates,  because,  with  the  exception 
of  certain  cases,  he  only  removes  a  part  of  the  infected  tissues,  and  then 
leaves  the  task  of  definite  conquest  to  nature. 

It  is  not  to  be  wondered  at,  therefore,  if  surgeons  have  interested  them- 
selves recently  in  finding  means  of  helping  the  natural  process  of  cure,  rather 
than  excogitating  new  operative  processes  aiming  at  a  complete  extirpation 
of  the  infected  region. 

At  this  time  the  prevailing  method  of  treatment  of  tuberculosis  of  the  joints 
has  conservative  tendencies,  inasmuch  as  surgical  intervention  is  resorted  to 
only  in  cases  of  exceptional  gravity,  and  this  applies  to  all  the  articulations, 
with  the  reservation,  however,  that  for  some  of  these,  under  more  favorable 
anatomical  conditions,  i.  e.,  knee,  elbow,  hinge-joint,  the  field  of  operation 
is  more  extensive  than  in  others.  The  rule,  however,  remains  the  same,  be- 
cause it  is  only  a  question  of  limiting  the  boundaries.  The  few  who  hold 
aloof  from  this  rule — Kocher,  for  example,  who  advocates  premature  in- 
tervention, even  in  coxitis — have  no  followers,  because  the  extirpation  of  an 
initial  osseous  focus,  which  has  already  given  rise  to  an  endoarticular  process, 
leaves  behind  it  the  diffused  alteration  of  the  articulation  and  conditions 
hardly  different  from  those  preceding  the  operation,  or  even  aggravated  by 
the  injury  resulting  therefrom.  To  this,  we  must  add  that  experience  has 
VOL.  II— 5  129 


130  SIXTH   INTERNATIONAL   CONGRESS    ON   TUBERCULOSIS. 

taught  US  that  the  cure  obtained  by  conservative  means  leaves  better  func- 
tional conditions. 

On  the  contrary  (and  this  may  be  inferred  from  what  I  have  said),  op- 
erative intervention  is  absolutely  indicated  if  the  osseous  focus  is  para-artic- 
ular, and  the  articulation  is  still  healthy.  The  extirpation  of  this  removes 
the  probability  of  the  process  eventually  extending  to  the  joint.  I  do  not 
intend  to  treat  this  subject  to  its  fullest  extent.  My  opinion  on  the  impor- 
tance and  limits  of  the  two  methods,  preservation  or  destruction,  is  not  differ- 
ent from  that  recently  expressed  by  the  surgeons  at  the  different  congresses, 
and,  especially,  at  that  of  the  Surgical  International  Society,  at  which  many 
of  my  views  were  expressed  in  a  report.  I  only  desire  to  call  attention  to 
the  importance  of  a  perfect  immobilization  of  the  affected  part,  which  is, 
in  my  opinion,  the  greatest  factor  in  the  cure.  If  tliis  does  not  meet  the  views 
of  every  one,  I  am  inclined  to  attribute  it  to  the  fact  that  immobilization  is 
often  applied  with  poor  judgment  and  defective  technic.  The  opponents  of 
the  method  insist,  also,  upon  the  harm  which  immobilization  causes  in  pro- 
ducing atrophy  of  the  tissues  and  articular  rigidity.  To  this  method, 
however,  alterations  have  been  attributed  which  are,  on  the  contrary,  direct 
consequences  of  the  tuberculous  process  itself.  The  atrophy  of  the  bones 
and  the  atrophy  and  functional  impotence  of  the  muscles  manifest  them- 
selves early  in  tuberculous  arthritis,  also,  when  the  part  is  not  made  im- 
movable, and  agree  with  a  greater  virulence  of  the  phlogosis.  The  rigid- 
ity of  the  articulation  is  due  to  the  transformation  of  the  diseased  tissues 
during  the  period  of  reparation.  Immobilization  in  itself  only  produces 
modifications  in  the  tissues,  which  adapt  themselves  to  the  new  functional 
state  of  the  part  which  has  been  rendered  immovable;  and  the  harm  which  it 
produces  is  easily  corrected  after  the  removal  of  the  apparatus.  Immobili- 
zation is  responsible  for  only  a  small  part  of  the  articular  rigidity  which  is 
noticeable  after  the  cure ;  and,  as  it  assists  the  healing  of  tuberculous  phlogo- 
sis, it  has  a  beneficial  influence,  also,  on  the  motor  function  of  the  articula- 
tion. There  can  be  no  doubt  of  the  truth  of  this  statement  when  we  remem- 
ber that  an  articulation  in  a  state  of  contracture  offers  much  less  passive 
resistance  to  straightening  after  a  period  of  immobility  than  before.  As  I 
shall  relate  further  on,  I  use  immobilization  to  facilitate  the  straightening 
of  the  contractures  in  tuberculous  arthritis. 

As  to  the  injury  which  the  apparatus  itself  may  cause,  we  must  consider, 
on  the  other  hand,  the  apparatus  which,  in  the  treatment  of  spondylitis, 
render  the  whole  body  immovable.  These  undoubtedly  hinder  the  develop- 
ment of  the  chest  and  the  relative  visceral  functions,  and  we  ought  to  re- 
member this  and  give  it  its  proper  weight  in  the  balance  with  the  pernicious 
effect  on  the  process  if  the  affected  region  were  not  rendered  immovable. 
In  the  greater  number  of  cases,  and  during  the  period  when  the  process 


IMMOBILIZATION   IN  TUBERCULOUS    ARTHRITIS. — CODIVILLA.  131 

maintains  an  invading  action,  this  latter  turns  the  balance  and  immobiliza- 
tion is  indicated. 

Let  us  now  pass  on  to  the  rules  which  must  be  applied  to  this  method  of 
treatment.  First  of  all,  immobilization  must  be  adopted  at  the  first  signs 
of  infection,  in  order  that  its  beneficial  effects  may  manifest  themselves  more 
clearly.  Therefore,  an  early  diagnosis  is  very  necessary,  I  tliink  that,  for 
this  purpose,  we  should  avail  ourselves  of  every  means  of  verifying  our  sus- 
picions of  the  signs  of  incipient  tuberculosis  of  the  joints,  and  that  radio- 
graphic examinations  and  tests  with  tuberculin  should  be  adopted  oftener 
by  the  practitioner. 

To  the  rule  of  applying  immobilization  as  soon  as  possible  must  be  added 
that  of  making  it  as  complete  as  possible  for  the  entire  period  during  which 
the  phlogosis  gives  certain  signs  of  its  presence.  The  pain,  fever,  and  tume- 
faction must  have  disappeared  before  we  should  think  of  permitting  certain 
movements  of  the  joints;  the  passage  from  immobilization  to  liberty  of  the 
articulation  should  be  gradual,  and,  by  degrees,  the  part  will  pass  from  a 
state  of  rigidity  to  one  of  flexibility.  In  this  period  importance  must  be 
attached  to  the  shghtest  signs  of  a  reawakening  of  the  process,  and  a  return 
made  to  the  application  of  continued  immobilization. 

It  is  very  difficult  to  decide  upon  the  right  moment  for  the  entire  or  par- 
tial removal  of  the  apparatus,  and,  for  the  most  part,  the  eye  and  common 
sense  of  the  practitioner  must  judge  when  the  first  attempts  at  liberation  of 
the  affected  part  can  be  made.  No  standard  rule  can  be  given  as  to  the 
time  required;  in  some  fortunate  cases  one  or  two  months  are  sufficient, 
while  in  the  greater  number  one  or  more  years  are  necessary. 

At  the  same  time  nothing  very  definite  can  be  said  as  to  the  moment 
when  we  may  pass  from  an  absolute  to  a  relative  immobilization  or  when  the 
apparatus  can  be  removed  and  the  weight  of  the  body  allowed  to  bear  upon 
the  part.  By  means  of  an  example  I  shall  show  what  my  own  personal  ex- 
perience has  taught  me.  In  the  so-called  florid  period  of  coxitis, — i.  e.,  when 
the  process  is  evidently  progressing, — after  a  period  of  observation,  wliich 
the  patient  passes  in  bed,  extended  by  weights,  I  render  the  affected  part 
immovable  by  means  of  a  plaster  apparatus  furnished  with  Kappeler's 
stirrups,  to  which  the  limb  in  extension  is  adjusted.  It  almost  always  hap- 
pens that  some  time  after  this  the  tendency  of  the  phlogosis  to  take  a  stronger 
footing  ceases,  and  the  affection  enters  an  apparently  stationary  period. 
On  removing  the  apparatus  it  is  observable  that  the  acuteness  of  the  symp- 
toms has  passed  and  that  some  slight  passive  movement  of  the  joint  is 
possible  without  pain.  On  the  application  of  extension  by  weight,  the  night 
will  pass  without  contractions  or  characteristic  cries.  If,  in  such  a  case, 
radiography  does  not  show  an  increase  of  the  atrophy  which  existed  before 
the  treatment  was  begun,  I  judge  that  the  right  moment  has  arrived  for  the 


132  SIXTH  INTERNATIONAL  CONGRESS   ON  TUBERCULOSIS. 

extension  to  be  removed.  I  then  apply  a  plaster  apparatus,  wliich  includes 
also  the  foot,  but  without  traction.  I  usually  leave  this  apparatus  for  three 
or  four  months,  and,  on  its  removal,  if  the  improvement  in  the  local  condi- 
tions has  continued,  and  if  the  nutrition  of  the  bone  is  also  good,  I  apply  a 
new  apparatus,  which  only  comes  down  to  the  malleolus,  leaving  the  foot 
free.  Thus  the  weight  of  the  body  bears  upon  the  injured  part,  and  this  with- 
out causing  any  harm  if  the  radiographic  shade  of  the  bones  is  dense,  and  if 
the  articular  lines  are  regular. 

I  differ  here  from  Lorenz,  who  considers  it  preferable  for  the  hip  to  bear 
the  weight  of  the  body.  In  experiments  made  at  Instituto  Rizzoli  on  two 
series  of  patients  in  almost  the  same  conditions,  and  treated,  one  with  the 
apparatus  permitting  the  pressure  of  the  joint,  and  the  other  without  the 
pressure,  the  results  were  more  satisfactory  in  the  latter  case.  The  cases  in 
which  the  joint  had  suffered  from  the  action  of  the  weight  of  the  body  in 
all  the  phases  of  the  illness  presented  shortening,  and  the  radiograph  showed 
a  cuneiform  deformity  of  the  head,  and  a  corresponding  excavation  of  the 
acetabulum.     The  pressure  had  favored  the  compressive  ulceration. 

After  another  period  of  some  months  the  apparatus  is  again  removed, 
and,  according  to  the  successive  improvement  of  the  local  conditions,  and 
after  a  sufficient  number  of  days  (passed  by  the  patient  in  bed  with  extension 
by  weights,  massage  of  the  leg,  and  exercises  of  the  knee-joint)  have  brought 
the  conditions  of  these  parts  to  such  a  point  that  we  need  not  fear  any  change 
in  the  circulation  of  the  leg,  or  irritation  of  the  knee,  when  once  they  are 
set  at  liberty,  a  new  plaster  apparatus,  reaching  as  far  as  the  femoral  con- 
dyles, renders  the  hip  immovable.  However  well  modeled  the  apparatus  may 
be,  it  does  not  prevent  slight  rotary  movements  of  the  femur  on  its  own 
longitudinal  axis,  and  the  joint,  too,  is  charged  with  the  weight  of  the  body. 

After  a  further  period  of  immobilization  this  apparatus  also  is  removed, 
and,  if  the  conditions  are  favorable,  it  may  be  substituted  by  a  similar  one 
of  leather,  which  can  be  taken  off  at  will,  to  permit  of  massage  and  any 
movements  that  may  be  deemed  necessary. 

The  example  explains  the  gradual  passage  from  the  cessation  of  the  artic- 
ular function  to  its  reacquirement,  first  by  making  the  weight  of  the  body 
act  upon  the  joint,  then  by  slight  rotary  movements  of  the  femur,  and  lastly, 
and  by  degrees,  all  the  other  movements. 

The  local  conditions  of  the  case  sometimes  require  special  and  repeated 
dressing  or  small  operations,  such  as  the  puncture  of  abscesses,  incisions,  etc. 
The  necessity  for  such  intervention  may  also  arise  during  the  immobiliza- 
tion treatment.  An  increased  accumulation  of  exudate  in  the  cavity  of  the 
joint,  the  infiltration  of  this  into  the  surrounding  spaces,  the  share  which  the 
■  periarticular  soft  parts  take  in  the  process,  the  formation  of  abscesses  which 
often  necessitate  these  small  interventions  in  the  spontaneous  evolution  of 


IMMOBILIZATION   IN  TUBERCULOUS    ARTHRITIS. — CODmLLA.  133 

the  morbid  process,  form  stages  which  may  often  be  regarded  as  favorable 
rather  than  othervvise. 

In  order  that  the  cure  may  not  be  interfered  with,  we  must  try  to  prevent 
the  pyogens  from  invading  the  focus,  and  must  maintain  the  immovabihty. 
This,  too,  is  a  help  to  the  prevention  of  a  mixed  infection.  With  im- 
mobihzation  and  a  free  use  of  antiseptics,  I  am  not  disturbed  by  an  opening 
in  the  cavity  large  enough  to  permit  of  the  rapid  emptjdng  of  the  residual 
products  of  the  inflammation.  In  this  way  a  rapid  spontaneous  closing  of 
the  abscess  almost  always  takes  place,  or  there  only  remains  a  fistulous 
sinus,  discharging  only  a  few  drops  of  pus,  which,  by  a  long  and  narrow 
canal,  opposes  sufficient  resistance  to  air  to  prevent  an  increase  of  infection, 
and  almost  always  ends  by  closing.  I  empty  abscesses  by  puncture  only 
when  they  are  small  and  deep. 

The  therapeutic  applications  to  which  I  have  alluded  are  not  unfavor- 
able to  immobilization,  because  the  apparatus  can  be  made  with  openings, 
or  it  can  leave  the  surrounding  region  free  by  joining  the  two  parts  by  means 
of  metal  bands;  in  some  cases  the  joint  can  be  rendered  immovable  by 
simple  extension. 

Naturally,  we  cannot  combine  immobilization  with  movements  or 
interventions  which  aim  at  remedying  positions  of  contracture  or  de- 
formities which  we  find  necessary  to  remove  in  order  to  benefit  the 
functions  of  the  limb.  However,  these  interventions  ought  to  be  used 
so  as  to  interfere  as  little  as  possible  with  the  effects  of  the  treatment 
of  the  deformities.  I  will  remind  you  that  the  traumatism  must  be  very 
slight  if  the  straightening  is  gradual,  and  pro\ided  that  we  try,  in  the  first 
place,  to  conquer  the  resistance  of  the  soft  parts,  and  after  that  to  modify 
the  formation  of  the  skeleton.  Extension  and  eventually  tenotomies  and 
aponeurotomies,  etc.,  will  serve  to  extend  the  soft  parts  which  occupy  the 
angle  of  the  deformity.  When  these  resistances  are  overcome,  the  correc- 
tive endoarticular  modifications  will  be  obtained  without  employing  any 
particular  force,  and,  consequently,  without  the  development  of  strong 
pressure  between  the  heads  of  the  joints,  and  with  minimum  trauma.  The 
extension,  which  must  precede  the  correction,  can  be  secured  in  the  usual 
manner,  by  traction  on  the  distal  segment  of  the  contractured  joint.  A 
strong  fixation  of  the  proximate  segment  during  the  distention  may  be  nec- 
essary sometimes,  and,  for  the  hip,  a  plaster  apparatus  is  excellent,  as  it 
includes  the  pelvis,  the  opposite  thigh,  and  the  lower  half  of  the  trunk,  and 
renders  the  movements  of  the  lumbar  column  less  easy.  When  once  the  ex- 
tension has  acted  for  the  necessary  time,  the  fixture  of  the  proximate  part 
renders  the  corrective  manipulations  more  secure,  and  facilitates  the  result. 
In  some  cases  I  close  the  two  segments  of  the  contractured  joint  in  a  plaster 
apparatus,  divide  this  circularly  at  the  spot  corresponding  to  the  angle  of 


134  SIXTH    INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

the  contracture,  and  open  the  distending  force  on  the  two  parts,  completing 
the  apparatus  after  the  correction.  This  is  often  obtained  by  degrees  after 
different  periods  of  an  application  of  drawing  power,  followed  by  corrective 
exercises  and  immobilization,  with  the  completion  of  the  apparatus.  In 
both  these  cases,  and  in  those  in  which  it  is  not  ad\dsabl3  to  correct  the  de- 
formity, in  the  periods  which  precede  the  complete  correction  I  facilitate 
walking  or  render  it  possible  by  inserting  in  the  proper  place  in  the  apparatus 
a  rigid  stick,  which,  like  a  pillar,  allows  the  proximate  segment  of  the  limb — 
or  of  the  pelvis,  if  the  hip  is  in  question — to  maintain  the  normal  position. 
The  patient  walks  on  the  artificial  limb  and  so  leaves  the  injured  part  in 
repose. 

And  now,  two  words  about  the  means  which  are  used  for  the  immobili- 
zation of  the  injured  joint.  They  are  two:  the  extension  of  the  joint  and 
the  apparatus  wdiich  inclose  it.  Extension  acts  by  opposing  to  the  muscles 
a  resistance  which  either  hinders  or  renders  their  contraction  difficult,  rather 
than  by  a  real  discharge  of  the  injured  joint;  so  we  eliminate  the  danger  that 
the  reflex  or  voluntary  contractions  of  the  muscles  with  the  movements,  and 
the  increase  of  pressure  which  they  cause  in  the  joint,  may  give  rise  to  trau- 
matic damage  to  the  injured  parts  and  favor  the  extension  of  the  morbid 
process.  On  the  contrary,  the  apparatus  tries  to  control  the  segments  of 
the  skeleton  which  form  the  joint,  and  to  adjust  them  in  such  a  manner  as 
to  prevent  the  possibility  of  any  movement.  This  is  absolutely  impossible 
in  practice,  because  the  soft  parts  which  cover  the  skeleton  prevent  the  ap- 
paratus from  taking  a  sufficient  hold  on  the  bones,  and  some  movement  of 
the  joint  is  possible.  Thus,  the  immobilization  will  be  more  secure  if  the 
two  methods  are  used  together,  i.  e.,  apparatus  and  extension.  This  is  in- 
dicated more  for  those  joints  with  short  bony  segments,  on  which  it  is  less 
easy  for  the  apparatus  to  get  a  hold.  In  the  hip,  for  instance,  it  is  difficult 
for  the  apparatus  to  get  a  sufficient  hold  on  the  pelvis,  and  the  joint  is  domi- 
nated by  very  strong  muscles;  therefore,  especially  for  the  hip,  we  must  often 
use  the  two  methods  together.  The  extending  force  can  act  in  a  contin- 
uous and  uniform  manner,  as  in  the  application  of  weights  or  in  elastic 
traction,  which  we  must  be  careful  to  maintain  quite  equally  or  it  may  lose 
its  strength  little  by  little  as  the  resistance  diminishes.  If  the  apparatus  is 
complete,  and  if  the  extremity  of  the  joint  is  fixed  in  Kappeler's  stirrup, 
thus  including  in  the  apparatus  itself  the  force  of  extension  which  acted 
during  the  construction  of  the  apparatus,  we  put  the  second  method  of  ex- 
tension into  practice.  When,  after  having  conquered  the  resistance,  we  wish 
to  make  use  of  extension  again,  we  must  divide  the  apparatus  into  two 
parts,  corresponding  to  the  locality  on  which  the  force  must  act;  and,  after 
the  application  of  this  force,  complete  the  apparatus  in  the  hollow  remaining 
between  the  two  disjoined  parts.    The  two  forms  of  extension  have  special 


IMMOBILIZATION   IN   TUBERCULOUS    ARTHRITIS. — CODIVILLA.  135 

indications.  Something  about  this  has  already  been  said  when  I  spoke  of 
the  correction  of  the  positions  of  contracture.  We  use  the  force  in  a  con- 
tinuous and  uniform  manner  when  we  "^dsh  to  combat  the  state  of  permanent 
muscular  contraction  which,  partly  voluntary  and  partly  reflex,  accompanies 
the  florid  period  of  the  illness.  In  this  period,  too,  in  order  that  the  immobili- 
zation and  the  action  of  the  force  may  have  the  best  results,  it  is  better  for 
the  patient  to  remain  in  bed.  This  also  permits  a  continual  observation  of 
the  affected  part,  which  will  give  indications  of  the  best  manner  of  conduct- 
ing the  treatment. 

As  I  have  given  you  to  understand  in  several  parts  of  my  lecture,  when 
there  are  indications  of  immobilization  in  an  apparatus,  which  happens  at 
the  end  of  the  period  of  observation,  I  always  have  recourse  to  the  immovable 
plaster  apparatus,  which  is  the  most  secure  in  the  holding  and  immobiliza- 
tion of  the  part,  the  most  easily  made,  and  the  cheapest.  The  plaster  ap- 
paratus answers  all  purposes  if  its  application  has  not  erred  in  conception 
and  technic.  In  conception  it  must  give — (a)  a  perfect  fixation,  and,  there- 
fore, must  come  up  to  the  segments  which  are  above  the  injured  articula- 
tions far  enough  to  afford  sufficient  hold,  and  must  also  fix  the  skeleton  by 
means  of  deep  modeling  on  its  most  exposed  parts  and  on  those  which  adapt 
themselves  as  points  of  support  to  the  apparatus:  (6)  slight  extension. 

In  regard  to  the  technic  of  its  construction,  this,  which  has  been  notably 
improved  recently,  permits  us  to  make  light  plaster  apparatus  which  hold 
the  skeleton  and  can  also  exercise  strong  extending  force  without  injury 
to  the  soft  parts,  and  which  last  a  long  time. 

The  apparatus  called  "ortopedici"  never  give  a  perfect  immobilization, 
and  I  only  use  them  as  a  precautionary  measure  in  the  period  which  follows 
recovery.  The  immobilization  treatment,  applied  in  the  above  described  way, 
is,  according  to  my  experience,  the  best  coefficient  to  healing  tuberculous 
joints  and  spondylitis;  and,  for  the  most  part,  when  it  is  applied  as  soon  as 
the  morbid  process  declares  itself,  it  is  enough  in  itself,  to  effect  a  cure  in  a 
comparatively  short  time.  It  is  a  method  of  treatment  within  the  reach  of 
every  one,  and,  for  this  reason,  merits  the  widest  circulation. 


La  Importancia  de  la  Inmovilizacion  en  la  Artritis  Tuberculosa. — 

(C'ODIVILLA.) 

El  parecer  del  Dr.  Codivilla,  esta  de  acuerdo  con  la  opinion  del  cuerpo 
de  cirujanos  de  varios  Congresos  Internacionales,  de  que  el  tratamiento  de 
la  artritis  debera  ser  conservative  solamente,  puesto  que  la  operacion  quita 
una  parte  del  tejido  afectado,  mas  deja  la  otra  parte  ya  infiltrada  de  la 
afeccion.  De  esto  hay  excepciones.  La  inmovilizacion  perfecta  (las 
objeciones  a  esta  son  debidas  a  descuidos  en  el  tecnisismo  ya  la  apHcacion 


136  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

irracional)  es  la  gran  ayuda  en  la  cura.  Atrofia,  y  rigidez  de  la  articulacion 
es  debido  al  proceso  tuberculoso,  puestoo  que  esto  ocurre  tambien  aun 
cuando  la  parte  no  esta  inmovilizada.  La  fijacion  produce  solamente  una 
pequena  parte  de  la  rigidez,  y  sera  de  gran  ventaja  en  el  uso  posterior  de 
la  articulacion,  es  indicada  por  el  hecho  de  que  la  articulacion  en  un  estado 
de  contraccion  ofrese  menos  resistencia  al  enderezarla  despues  de  un  periodo 
de  inmovilizacion  que  antes.  Moldes  de  la  pasta  de  Paris  en  casos  de 
espondilitis,  son  perjudiciales,  por  que  estos  interfieren  con  el  desarrollo 
del  pecho,  etc.,  mas  en  gran  parte  de  los  casos,  y  durante  el  proceso  de  la 
invasion,  estas  objeciones  desaparecen  a  causa  de  las  ventajas  del  proceso 
local  por  medio  de  la  inmovilizacion.  Esta  medida  debera  adoptarse  en 
los  primeros  signos  de  la  lesion;  por  lo  tanto  los  signos  iniciales  deberan 
ser  estudiados;  los  resultados  del  examen  por  los  rayos  X,  son  mas  frecuente- 
mente  confirmados  por  medio  de  las  inyecciones  de  tuberculina.  La  in- 
movilizacion debera  ser  completa  durante  el  periodo  de  los  sintomas  de  la 
inflamacion  y  el  movimiento  de  la  parte  ejercitado  gradualmente.  No  se 
pueden  dar  reglas  sobre  este  punto. 

El  metodo  del  Dr.  Codivilla  en  la  coxitis,  es  elllamado  estado  "florido," 
guardar  al  paciente  en  la  cama  con  pesas  solamente  durante  un  periodo  de 
observacion.  La  parte  es  entonces  inmovilizada  por  medio  de  un  molde, 
y  con  un  estribo  de  Kappelers  para  continuar  la  traccion.  Cuando  los 
sintomas  agudos  han  desaparecido  completamente,  la  traccion  se  quita,  y 
mas  tarde  un  nuevo  molde  es  aplicado  dejando  el  pie  lib  re,  y  permitiendo 
el  peso  del  cuerpo,  esto  es  cuando  las  sombras  de  la  radiografia  son  densas 
y  las  lineas  de  la  articulacion  son  regulares.  Despues  de  un  periodo  regular 
de  tiempo,  se  quita  el  molde  de  nuevo  y  el  paciente  es  guardado  por  algun 
tiempo  considerable  en  la  cama  con  extension,  y  mientras  tanto  masage, 
ejercicios  ligeros  de  la  rodilla  deberan  emplearse  para  guardar  el  equilibrio 
de  la  circulacion  del  miembo.  Despues  se  aplica  un  nuevo  molde  se  aplica 
a  los  condiles  del  femur.  Esto  previene  movimiento  con  la  excepcion  del 
de  rotacion,  y  la  articulacion  ahora  soporta  el  peso.  Finalmente  se  aplica 
un  aparato  de  cuero,  de  tal  modo  que  el  massage  y  la  mocion  pasiva  puedan 
aplicarse. 

Incision  6  abertura  de  los  abscesos  no  interfieren  con  la  inmovilizacion. 
La  formacion  de  pequenos  abscesos  pueden  ser  favorables.  Una  infeccion 
mixte  debere  evitarse  por  medio  de  la  antisepcia.  Abertura  puede  hacerse 
en  el  molde. 

A  fin  de  evitar  las  contracciones  y  las  deformidades,  el  Dr.  Codivilla 
recomienda  evitar  el  tromatismo  en  tanto  cuanto  sea  posible.  Debera 
vencerse  primero  la  resistencia  de  los  tejidos.  Traccion,  eurotomia  y 
oponeurotomia  pueden  ser  requeridas.  Despues  la  modificacion  de  la 
deformidad  endoarticular  no  necesitara  fuerza. 


IMMOBILIZATION   IN   TUBERCULOUS    ARTHRITIS. — CODIVILLA.  137 

El  Dr.  Codivilla  describe  su  metodo  por  medio  de  la  aplicacion  del  molde 
en  estos  casos. 

El  valor  de  la  inmovilizacion  de  la  articulacion,  es  notablemente  aument- 
ada  por  medio  del  empleo  de  uno  de  los  metodos  de  traccion,  puesto  que 
esto  evita  los  movimientos  voluntarios  y  reflejos  de  los  musculos,  lo  cual 
daria  por  consecuencia  poner  los  huesos  en  contacto  con  la  articulacion,  y 
de  este  modo  producir  un  tromatismo.  Durante  el  estado  "florido"  esta 
fuerza  debera  ser  continua. 

La  inmovilizacion  (por  medio  de  un  extenso  y  bien  aplicado  molde), 
combinado  con  la  traccion,  segun  la  experiencia  del  Dr.  Codivilla,  es  el 
mejor  metodo  en  la  cura  de  la  spondilitis  tuberculosa  y  la  tuberculosis  de 
las  articulaciones. 


Importance  de  I'immobilisation  dans  I'arthrite  tuberculeuse. — (CoDI\^LLA.) 
L'auteur  dit  que  le  traitement  de  Tarthrite  tuberculeuse  doit  etre  con- 
servateur,  puisque  I'operation  ne  fait  qu'eloigner  un  foyer  de  la  maladie  de 
I'os  et  laisse  I'articulation  infiltree.  II  y  a  des  exceptions.  L'immobili- 
sation  parfaite  (les  objections  contre  cette  methode  sont  dues  a  des  fautes 
dans  la  technique  et  a  une  application  non  rationnelle)  est  la  meilleure  aide 
dans  le  traitement.  L'auteur  attribue  I'atrophie  et  la  rigidite  articulaire 
au  proces  tuberculeux,  car  elles  ont  lieu  meme  quand  le  membre  n'est  pas 
immobilise.  Pour  demontrer  que  la  fixation  ne  produit  qu'une  petite 
partie  de  la  rigidite  et  qu'elle  est  avantageuse  parce  que,  finalement,  elle 
augmente  la  possibilite  de  faire  usage  de  I'articulation,  l'auteur  dit  qu'une 
articulation  contractee  offre,  apres  un  temps  d'immobilite,  beaucoup  moins 
de  resistance  au  redressement,  qu'avant  ce  temps  d'immobilite.  L'emploi 
du  platre  dans  la  spondylite  empeche,  il  est  vrai,  le  d^veloppement  de  la 
poitrine  etc.,  mais  dans  la  plupart  des  cas,  et  pendant  le  proces  d'invasion, 
ces  objections  sont  compensees  par  les  avantages  de  I'immobilisation  pour 
la  lesion  locale. 

On  doit  adopter  cette  mesure  des  les  premiers  signes  de  la  lesion.  On 
doit,  par  consequent,  etudier  les  signes  initiaux,  employer  les  rayons  X  et 
tacher  de  faire  confirmer  le  diagnostic  par  les  injections  de  tuberculine, 
L'immobilisation  doit  etre  stricte  pendant  la  periode  des  symptomes  in- 
flammatoires  et  on  ne  doit  commencer  par  la  mobilite  que  vers  la  fin  du 
traitement  et  la  faire  graduellement.  On  ne  pent  donner  de  regie  exacte 
pour  cela. 

La  m6thode  pour  la  coxite,  dans  la  phase  appelee  "florissante,"  consiste 
k  tenir  le  malade  au  lit,  n'employant  que  des  poids,  pendant  un  temps 
d'observation.  Ensuite,  I'articulation  est  rendue  immobile  par  un  bandage 
en  platre  avec  des  ^triers  de  Kappeler,  pour  continuer  la  traction  ant(§rieure. 


13S  SIXTH    INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

Quancl  les  symptomes  aigus  clisparaissent  tout  a  fait,  on  eloigne  rinstrument 
de  traction  et,  plus  tard,  on  applique  un  nouveau  platre,  qui  laisse  le  pied 
libre,  a  condition  que  Kombre  radiographique  de  la  partie  lesee  soit  epaisse 
et  que  les  lignes  articulaires  soient  r^gulieres.  Apres  quelque  temps  ce 
platre  est  enleve  de  nouveau  et  on  garde  le  malade  au  lit,  avec  un  instrument 
d'extension,  pendant  un  temps  variable,  selon  le  cas;  pendant  ce  temps  on 
fait  des  massages  a  la  jambe  et  des  mouvements  passifs  au  genou,  pour 
activer  la  circulation.  Ensuite,  on  applique  un  nouveau  platre  qui  atteint 
les  condyles  du  femur,  ce  qui  ne  permet  qu'un  seul  mouvement  de  I'articu- 
lation  malade,  la  rotation,  et,  maintenant,  la  jointure  porte  le  poids  du 
corps.  Enfin,  un  appareil  en  cuir  qu'on  puisse  ajuster,  pent  etre  substitue, 
de  sorte  qu'on  puisse  faire  des  massages  et  des  mouvements  passifs. 

Les  incisions  ou  les  ponctions  d'absces  n'empechent  pas  I'immobilisation. 
La  formation  de  petits  absces  peut  etre  favorable.  Une  infection  mixte 
doit  etre  evitee  par  I'antisepsie.  On  peut  faire  des  ouvertures  dans  le 
platre. 

Dans  le  traitement  des  contractures  et  des  difformites,  il  faut  qu'il  y 
ait  le  moins  de  traumatisme  possible.  On  doit  d'abord  vaincre  la  resistance 
des  parties  molles.  On  peut  avoir  besion  de  faire  des  tractions,  des  nevroto- 
inies  et  des  aponevrotomies.  La  modification  des  difformites  endoarticu- 
laires  ne  demandera  I'emploi  d'aucune  force  particuliere. 

Methode  de  I'auteur,  de  la  traction  au  moyen  d'un  platre,  employee 
dans  ces  cas. 

La  valeur  de  I'immobilisation  de  I'articulation  par  le  platre  est  beaucoup 
accrue  par  I'emploi  d'une  des  methodes  de  traction,  parce  que  par  la  les 
contractions  musculaires  volontaires  et  reflexes,  qui  ont  pour  consequence 
I'attouchement  des  os  de  I'articulation,  n'ont  pas  lieu  et  ainsi,  la  cause  du 
traumatisme  dans  la  partie  lesee,  disparait.  Dans  la  phase  "florissante," 
la  traction  doit  etre  continuelle. 

L'immobilisation  (produite  par  des  platres  etendus  et  bien  modeles) 
combinee  avec  la  traction  est,  la  meilleure  methode  pour  guerir  la  tuber- 
culose  des  articulations  et  la  spondylite. 


Die  Wichtigkeit  der  Unbeweglichkeit  bei  tuberkuloser  Arthritis. — (Codi- 

VILLA.) 

Dr.  Codi villas  Ansichten  sind  in  Ubereinstimmung  mit  jenen,  die  durch 
die  Chirurgen  bei  den  verschiedenen  internationalen  Kongressen  ausge- 
driickt  wurden,  dass  die  Behandlung  der  tuberkulosen  Arthritis  konservativ 
sein  soil,  seitdem  operative  Massnahmen  nur  einen  Herd  der  Knochener- 
krankung  entfernen  und  das  Gelenk  infiltriert  lassen.     Dazu  gehoren  einige 


IMMOBILIZATION   IN   TUBERCULOUS    ARTHRITIS. — CODIVILLA.  139 

Ausnahmen.  Vollstandige  Unbeweglichkeit  (die  Einwendungen  dagegen 
sind  auf  nachlassige  Technik  und  unrationelle  Anwendung  zuruckzufiihren) 
ist  die  grosste  Hilfe,  um  Heilung  zu  erzielen.  Atrophie  und  Gelenksteifheit 
schreibt  er  dem  tuberkulosen  Prozesse  zu,  seitdem  sie  vorkommen,  wenn 
der  Teil  nicht  unbeweglich  gemacht  wurde.  Dass  Fixation  nur  sehr  wenig 
Unbeweglichkeit  hervorinift,  and  von  Vorteil  sein  wird,  um  zuletzt  die 
Gebrauchsfahigkeit  des  Gelenkes  zu  steigern,  ist  durch  die  Tatsache  be- 
wiesen,  dass  eine  Articulation  in  einem  Stadium  der  Kontraktion  viel 
weniger  Widerstand  einer  Starkung  gegeniiber  leistet,  nach  einer  Periode 
der  Unbeweglichkeit,  als  friiher.  Gipsverbande  fiir  Spondjditis  sind  schad- 
lich,  da  sie  die  Entwickelung  des  Brustkorbes  verhindern,  etc.,  aber  in  der 
grosseren  Zahl  der  Falle  und  wahrend  der  Prozess  sich  entwickelt,  sind  diese 
Einwendungen  iiber^-ogen  durch  die  Vorziige  dem  lokalen  Prozesse  gegen- 
iiber durch  Unbeweglichkeit. 

Die  Massnahmen  miissen  bei  den  ersten  Anzeichen  einer  Verletzung 
vorgenommen  werden.  Deshalb  sollten  die  anfanglichen  Zeichen  studiert 
werden,  x-Strahlen  angewendet,  und  die  Diagnose  haufiger  durch  TuberkuUn 
Injektionen  bestatigt  werden.  Die  Unbeweglichkeit  sollte  durch  aus 
wahrend  der  Zeitdauer  entziindlicher  Prozesse  vollstandig  sein,  und  Be- 
wegung  schliesslich  sehr  langsam  eingefiihrt  werden.  Es  kann  dafiir  keine 
Kegel  aufgestellt  werden. 

Er  beschreibt  seine  Zugmethode  durch  Anwendung  von  Gipsverbanden 
in  diesen  Fallen. 

Der  Wert  der  Unbeweglichmachung  des  Gelenkes  mit  Gipsverband 
wird  sehr  unterstiitzt  durch  die  Anwendung  einer  der  Zugmethoden,  well 
die  willkiirliche  und  reflektorische  Muskelkontraktion  die  Knochen  des 
Gelenkes  zusammenbringen,  und  derartig  ein  Trauma  in  dem  erkrankten 
Telle  hervorrufen  wiirde.  In  dem  "floriden"  Stadium  sollte  dies  fort- 
gesetzt  werden. 

Unbeweglichkeit  (hervorgerufen  durch  Zug  verursachende  und  gut 
modelherte  Verbande)  in  Verbindung  mit  Zug  ist  nach  Dr.  Codivillas 
Erfahrung  die  beste  Methode  fiir  die  Heilung  tuberkuloser  Gelenke  und 
von  Spondylitis. 


DE    L'OBLITERATION    DES    CAVITES    OSSEUSES    ET 

ARTICULAIRES   TUBERCULEUSES   AVEC  LA 

PATE   DE   MOSETIG. 

Par  Novfe-JossERAND, 

Professeur  il  1' University,  de  Lyon. 


Nous  avons  fait  quelques  tentatives  d' obliteration  des  cavites  cons^cu- 
tives  a  Tevidement  de  foyers  tuberculeux  osseux,  ou  a  des  resections  articu- 
laires  avec  le  melange  de  Mosetig  compose  de:  iodoforme  60,  blanc  de 
baleine  40,  huile  de  sesame  40. 

La  technique  employee  a  ete  la  suivante:  les  lesions  tuberculeuses  dia- 
physaires  ou  juxta-epiphysaires  etaient  evidees  avec  la  curette  ou  le  couteau- 
gouge,  de  fagon  a  enlever  non  seulement  les  tissus  malades  mais  aussi  tous 
les  tissus  douteux.  On  extirpait  aussi  aux  ciseaux  ou  a  la  curette  les  masses 
fongueuses  developpees  autour  de  I'os  et  la  membrane  pyogenique  des  abces 
froids.  Ensuite,  la  cavite  etait  soigneusement  assechee,  et  sterilisee  par 
I'air  chaud.  Alors  on  coulait  a  son  interieur  le  melange  iodoforme,  apres 
I'avoir  ramolli  en  la  portant  a  une  temperature  de  55°. 

Dans  les  arthrites  tuberculeuses,  la  resection  a  toujours  ete  faite  suivant 
la  methode  d' Oilier,  c'est  a  dire  sous  capsulo-periostee.  Apres  avoir  abrase 
les  surfaces  articulaires,  on  evidait  les  foyers  tuberculeux  qui  se  trouvaient 
dans  les  epiphyses,  on  excisait  la  synoviale  en  conservant  la  capsule  fibreuse 
de  r articulation,  on  evidait  aussi  les  masses  fongeuses  periarticulaires  et 
les  abces  froids,  puis  apres  hemostase  soigneuse  on  remplissait  tout  I'espace 
vide  avec  le  melange  plastique. 

Nous  avons  applique  cette  methode  dans  16  cas  d'osteite  tuberculeuse 
se  decomposant  ainsi:  un  cas  d'osteite  de  I'hum^rus  chez  un  nourrisson,  avec 
extension  k  la  moelle  dans  toute  sa  longeur;  un  cas  d'osteite  juxta-epi- 
physaire  inferieure  de  I'hum^rus  avec  cavity  du  volume  d'un  petit  oeuf, 
drainee  sans  resultat  depuis  10  mois:  un  petit  foyer  sous  periostique  de  la 
diaphyse  du  cubitus;  deux  ost6ites  juxta-^piphysaires  du  tibia;  onze  cas 
enfin  de  spina  ventosa  des  metacarpieijs  des  m^tatarsiens  ou  des  phalanges. 

La  reunion  par  premiere  intention  a  6te  obtenu  7  fois,  et  dans  tous  ces 
cas  la  gu6rison  se  maintient.  Les  9  autres  malades  ont  eu  de  la  desunion 
de  leur  plaie  et  une  elimination  partielle  du  melange.     La  plus  grande  partie 

140 


OBLITERATION    DES    CAVITfes    OSSEUSES. — NOVE-JOSSERAND.  141 

de  celui-ci  est  neanmoins  rest^e  en  place  dans  le  plus  grand  nombre  des  cas, 
et  tous  ont  gueri  dans  un  laps  de  temps  de  quinze  jours  a  trois  mois. 

Plusieurs  fois,  on  a  pu  suivre  par  la  radiographie  la  resorption  du  melange. 
Celle-ci  se  fait  plus  ou  moins  vite  suivant  les  dimensions  de  la  cavite;  elle 
demande  en  general  de  un  a  cinq  mois. 

Nous  comptions  egalement  10  cas  de  resection  articulaire:  une  resection 
de  I'extremite  superieure  du  radius;  une  du  poignet;  deux  de  la  hanche; 
une  du  genou;  deux  ablations  de  I'astragale,  dont  une  avec  evidement  du  cal- 
caneum;  une  ablation  du  calcaneum;  une  tarsectomie  anterieure  et  une 
tarsectomie  totale  avec  ablation  de  tous  les  metatarsiens. 

La  reunion  immediate  fur  obtenue  dans  le  cas  de  resection,  de  Textrem- 
ite  superieure  du  radius.  Dans  la  resection  du  poignet,  les  deux  astragal- 
ectomies,  et  la  tarsectomie  partielle,  la  reunion  ne  fut  pas  tout  a  fait  com- 
plete, il  y  eut  quelques  fistulettes,  notamment  au  niveau  du  drain;  nean- 
moins la  guerison  fut  a  peu  pres  complete  au  bout  d'un  mois.  Dans  le  cas 
d' ablation  de  I'astragale  le  melange  fut  elimine  en  totalite,  mais  la  plaie  se 
reunit  ensuite  rapidement.  Enfin  dans  les  resections  de  la  hanche,  du 
genou,  et  dans  la  tarsectomie  totale,  il  se  fit  de  la  suppuration  avec  elimina- 
tion partielle  du  melange.  Nous  avons  cependant  I'impression  que  chez 
ces  malades,  les  suites  operatoires  ont  ete  plus  simples  que  dans  les  autres 
cas  traites  par  le  drainage  seul,  et  que  la  guerison  a  ete  plus  rapide. 

Ces  faites  sont  en  somme  assez  semblables  a  ceux  qui  ont  ete  rapportes 
par  Mosetig  lui  meme;  ils  s'en  differencient  cependant  sur  deux  points. 
C'est  d'abord  que  toutes  ces  interventions  ont  ete  faites  pour  des  lesions 
assez  avancees.  apres  essai  souvent  prolonge  des  moyens  conservateurs 
ordinaires.  Mosetig,  au  contraire  est  partisan  d'intervenir  de  bonne  heure 
des  que  le  diagnostic  de  la  nature  tuberculeuse  est  pose.  Nous  voulons 
faire  remarquer  en  second  lieu,  que  dans  tous  les  cas,  nous  avons  fait  un  simple 
evidement  tres  complet  et  non  pas  la  large  exerese  que  recommandait  Mose- 
tig. De  meme  dans  les  resections,  nous  avons  toujours  conserve  la  capsule 
articulaire,  en  faisant  seulement  un  dissection  soigneuse  de  la  synoviale. 
Nos  observations  montrent  que  Ton  pent  obtenir  des  resultats  satisfaisants 
avec  des  operations  assez  economiques  pour  ne  rien  compromettre  de  la 
fonction  ulterieure  du  membre. 

Le  melange  de  Mosetig  parait  agir  a  la  faQon  d'un  pansement  interne  tr^s 
antiseptique,  qui,  tantot  se  resorbe,  tantot  s'^limine  par  les  fistules.  Dans 
un  cas  comme  dans  I'autre,  il  protege  les  bourgeons  r(§parateurs  de  la  plaie 
contre  I'infection  secondaire,  il  les  excite  h  rendre  leur  maximum  d'effet, 
Ainsi  le  traitement  est  a])r6ge  la  suppuration  diminuee  ou  supprimee,  les 
malades  sont  plus  vite  en  6tat  de  reprendre  leur  vie  normale,  et  la  guerison 
parait  aussi  plus  definitive. 


142  SIXTH   INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

Obliteration  von  tuberkulosen  Knochen-  und  Gelenkshohlen  durch  die 
Mosetig  Paste. — (Nove-Josserand.) 

Dr.  Nove-Josserand  berichtet  16  Fiille  von  tuberkuloser  I^ochenent- 
ziindung  und  10  Falle  von  tuberkuloser  Gelenksentziindung,  behandelt  durch 
Ausleerung  und  Resektion,  und  nachher  mit  Einspritzung  von  Mosetig's 
lodoform-Gemenge.  Unmittelbare  Heilung  wurde  in  7  Fallen  von  Knochen- 
entziindung  erlangt,  und  in  einem  Falle  von  Arthritis.  In  den  meisten 
andern  Fallen  erfolgte  voUstandige  Wiederherstellung  in  ungefahr  einem 
Monat.  Langere  Eiterung  wurde  nur  in  2  Fallen  von  Resektion  der  Hiifte 
und  in  einer  Resektion  des  Kniees  beobachtet. 

Das  Interesse  dieser  Beobachtungen  licgt  in  der  Tatsache,  dass  die 
zufriedenstellenden  Erfolge  erhalten  wurden  durch  achtsame  Entleerung 
der  Hohlen  ohne  die  von  Mosetig  empfohlene  extensive  Auskratzung,  und 
bei  den  Resektionen  mit  Erhaltung  der  Gelenkkapseln. 

Die  Methode  der  Obliteration  mit  dem  lodoform-Gemenge  lasst  sich 
deshalb  leicht  mit  konservativen  Operationen  vereinigen,  und  gefahrdet 
nicht  die  Funktionsleistung  des  ergriffenen  Teiles. 


Obliteration  of  Tuberculous  Bony  and  Articular  Cavities  with 
Mosetig  Paste. — (Nov6-Josserand.) 

Dr.  Nove-Josserand  reports  16  cases  of  tuberculous  osteitis  and  10 
cases  of  tuberculous  arthritis  treated  by  evacuation  or  resection,  fol- 
lowed by  the  injection  of  Mosetig's  iodoformized  mixture.  Immediate 
union  was  obtained  in  7  cases  of  osteitis  and  in  1  case  of  arthritis.  In 
most  of  the  remaining  cases  complete  recovery  ensued  in  about  a  month. 
Prolonged  suppuration  was  observed  in  only  2  cases  of  resection  of  the 
hip  and  in  1  resection  of  the  knee. 

The  interest  of  these  observations  lies  in  the  fact  that  these  satisfactory 
results  were  obtained  by  careful  evacuations  of  the  lesions  without  the 
extensive  scraping  recommended  by  Mosetig,  and,  in  the  case  of  resections, 
with  preservation  of  the  articular  capsule.  The  method  of  obliteration 
with  the  iodoformized  mixture  is  therefore  compatible  with  conservative 
operations  and  does  not  jeopardize  the  ultimate  functional  integrity  of 
the  part. 


Obliteracion  de  las  Cavidades  delos  Huesos  y  de  la  Tuberculosis  Articular 
por  Medio  de  la  Pasta  de  Mosetig. — (Nove-Josserand.) 
Dr.  Nov^-Josserand  presenta  diez  y  seis  casos  de  ostitis  tuberculosa  y 
diez  casos  de  artritis  tuberculosa  tratados  por  medio  de  la  evacuacion  6 


OBLITERATION    DES    CAVITES   OSSEUSES. — NOVE-JOSSERAND.  143 

reseccion,  seguida  por  la  injeccion  de  una  mistura  de  yodoformo  y  la  pasta 
de  Mosetig.  Union  inmediata  fue  obtenida  en  7  casos  de  ostitis  y  en  1  caso 
de  artritis.  En  la  mayor  parte  de  los  casos  restantes  una  recuperacion 
completa  fue  obtenida  en  casi  de  un  mes.  Supuracion  prolongada  se  ob- 
serve solamente  en  2  casos  de  reseccion  de  la  articulacion  de  la  cadera  y  en 
1  de  reseccion  de  la  rodilla. 

El  interes  de  estas  observaciones  consiste  en  el  hecho  de  que  resultados 
satisfactorios  fueron  obtenidos  por  medio  de  una  evacuacion  cuidadosa 
de  la  lesion  sin  recurir  a  la  raspadura  extensa  recomendada  por  Mosetig, 
y  en  el  caso  de  reseccion,  con  preservacion  de  la  capsula  de  la  articulacion. 
El  metodo  de  obliteracion  con  esta  mistura  es  por  lo  tanto  compatible 
con  la  operacion  conservativa  sin  afectar  la  integridad  funcional  de  la  parte. 


THE  VALUE   OF   THE   ROENTGEN  METHOD   IN  THE 

EARLY  RECOGNITION  OF   TUBERCULOSIS 

OF   BONES   AND  JOINTS. 

By  Carl  Beck,  M.D., 

Professor  of  Surgery  in  the  New  York  Postgraduate  Medical  School  and  HospitaU 


The  Roentgen  method,  in  reflecting  the  various  anatomical  changes  in 
the  tissues,  enables  us  frequently  to  recognize  a  tuberculous  focus  at  a  stage 
in  which  our  clinical  methods  failed,  thus  making  early  and  conservative 
therapy  possible.  The  changes  are  not  only  proportionate  to  the  different 
intensity  and  extent  of  the  tuberculous  process,  however,  but  are  also  de- 
pendent upon  the  texture  of  the  various  bones.  It  is  well,  therefore,  to 
consider  that  the  predilection  of  the  disease  is  for  the  epiphyses  of  the  long 
bones  and  the  diaphyses  of  the  short,  like  the  metacarpus  and  metatar- 
sus, the  small  spongy  bones,  like  the  carpus,  tarsus,  and  vertebrae,  while 
flat  bones,  like  the  skull  and  scapula,  are  seldom  the  seat  of  the  process. 
Only  the  ribs  are  to  be  excepted.  The  visible  changes  begin  when  the 
bacillus,  after  invading  the  bone  substance  through  the  circulation  as  a 
bacterial  embolus,  affects  the  blood-vessels,  and  in  multiplying  produces  a 
number  of  nodules,  which  gradually  destroy  the  m.edullary  tissues;  in  other 
words,  the  medium  of  nutrition  of  the  bone.  The  trabeculse  become  ab- 
sorbed, and  a  granulating  focus,  largely  composed  of  tubercles,  takes  their 
place.  Such  foci  may  be  of  a  circumscribed  character,  may  form  in  one  bone 
only  or  in  several  at  the  same  time,  or  multiple  foci  may  estabhsh  themselves 
in  one  and  the  same  bone.  Where  there  is  a  strong  tendency  to  diffusion  and 
decay,  the  changes  show  the  cheesy  character,  the  tissues  becoming  more  and 
more  infiltrated,  as  is  especially  observed  at  the  diaphysis  of  the  short  bones 
of  the  metatarsus,  the  metacarpus,  and  the  digits.  There  a  circumscribed 
focus  seldom  establishes  itself,  the  whole  diaphysis,  as  a  rule,  becoming  a 
sequestrum.  A  circumscribed  focus,  confining  itself  to  the  center  of  the 
bone,  may  remain  there  for  a  long  time  in  temporary  innocence,  no  clini- 
cal evidence  of  it  manifesting  itself  until  some  irritation  sets  up  an  inflamma- 
tory process,  which  is  followed  by  further  spreading  of  the  tuberculous  pro- 
cess. Then  the  surface  of  the  bones  may  be  reached,  and  the  proliferation 
of  the  periosteum  there  produces  new  bone,  while  in  the  deeper  region  the 
old  bone  is  absorbed.     This  process  finds  conspicuous  exterior  expression 

144 


THE   ROENTGEN-RAT   IN   EARLY   DIAGNOSIS. — BECK.  145 

in  the  spindle-shaped  enlargement  of  the  bone-circumference.  The  homo- 
logue  of  this  combination  of  gradual  destruction  and  construction  is  the  os- 
teomyelitis of  the  phalanges,  ordinarily  called  spina  ventosa.  The  same 
macroscopical  impression  prevails  when  the  process  of  destruction  confines 
itself  to  the  cortex,  while  the  center  of  the  diaphysis  still  shows  healthy  zones. 
Roentgen  examination  gives  the  most  marked  expression  of  these  anatomi- 
cal changes.  If,  in  the  circumscribed  form  of  tuberculous  osteomyelitis, 
as  described  above,  the  trabecule  are  gradually  absorbed,  granulations 
taking  the  place  of  the  osseous  tissue,  the  metamorphosed  area  appears 
translucent.  The  more  extensive  the  changed  area,  the  greater  the  absorp- 
tion of  calcareous  matter,  consequently  the  greater  the  translucency  of  the 
affected  sphere.  The  formation  of  caseous  substance  alters  this  condition 
but  little.  The  cortex  appears  to  be  more  or  less  distended.  In  long  bones 
there  is  little  periosteal  proliferation,  while  in  short  bones  it  is  abundant. 

As  soon  as  a  circumscribed  focus  perforates  the  cortex,  its  formerly 
regular  shadow  becomes  interrupted,  and  some  of  the  portions  appear  con- 
fluent. 

In  the  infiltrating  type  of  tuberculous  osteomyelitis  osteoporosis  is  found. 
Some  of  the  osseous  tissue  is  absorbed,  just  as  in  the  circumscribed  type, 
but  most  of  it  becomes  necrotic  by  the  inhibition  of  nutrition.  The  skia- 
graphic  expression  of  this  process  is,  therefore,  entirely  different  from  that  in 
the  circumscribed  foci.  Sequestra  appear  as  dark  shadows,  the  absence  of 
textural  details  characterizing  them  as  dead  bone  tissue. 

The  Roentgen  method  not  only  diagnosticates  the  presence  of  a  focus — ■ 
it  also  localizes  it  and  outlines  its  extent  so  well  that  the  steps  of  an  operation 
can  be  definitely  traced  in  advance,  the  skiagraph  serving  as  a  mentor  before 
and  during  the  operation. 

Intraosseous  foci  are  found  at  the  periphery  as  well  as  in  the  middle. 
They  may  be  globular,  elliptic,  or  tubular.  If  tubular,  the  focus  may  per- 
meate the  whole  epiphysis,  and  joint  perforation  may  take  place.  If  this 
occurs  in  the  hip-joint,  further  perforation  may  take  place  into  the  retro- 
peritoneal space,  and  a  subphrenic  abscess  may  finally  form.  If  there  be, 
as  described  above,  a  disturbance  of  nutrition,  an  area  of  necrosis  may  form, 
which  in  most  instances  assumes  the  shape  of  a  triangle,  the  base  of  which 
will  be  near  the  joint  surface.  This  phenomenon  is  explained  by  the  ar- 
rangement of  the  nutrient  vessels,  which  diverge  from  the  medulla  toward  the 
cartilaginous  surface,  so  that  just  the  area  supplied  by  these  vessels  will 
become  necrotic  if  the  nutrition  is  inhibited.  Thus  a  cuneiform  sequestrum 
is  formed.  It  may,  however,  also  be  of  a  more  rhomboid  character  in  pro- 
portion to  the  different  shape  of  the  articular  ends  of  the  various  bones. 
The  color  of  the  necrotic  bone  portion  is  white  at  the  beginning,  as  the  me- 
dulla and  Haversian  canals  are  interwoven  with  pus-cells  and  cheesy  tubercles. 


146  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

In  the  further  course  of  the  exfoliation  process  a  thin  granulation  stratum 
forms  as  the  only  means  of  coherence  between  the  sequestrum  and  the  heal- 
thy tissue.  The  clinical  symptoms  may  be  slight  in  such  cases,  because  the 
development  of  the  process  is  slow,  and  pain  as  well  as  functional  disturb- 
ance may  be  insignificant.  But  the  skiagraph  shows  the  contrast  between 
the  dead  and  the  healthy  area  convincingly. 

Articular  tuberculosis  is  more  frequent  than  the  osseous  type,  and  repre- 
sents, in  fact,  the  most  predominant  joint  disease.  The  insidious  character, 
especially  the  slow  development  of  tliis  variety,  makes  an  early  diagnosis 
without  the  aid  of  the  Roentgen  method  impossible  in  most  cases.  As  is 
well  known,  at  first  either  the  synovial  membrane  or  the  osseous  epiphyses 
become  involved,  the  synovialis,  as  a  rule,  being  attacked  first.  In  the  latter 
the  process  may  be  circumscribed  or  diffuse.  The  circumscribed  type  is 
rare,  and  confines  itself  mostly  to  the  fibrous  portions  of  the  synovial  mem- 
brane, where  it  forms  hard  nodules  which  may  vary  between  the  size  of  a 
filbert  to  that  of  a  walnut.  They  consist  of  <young  connective  tissue,  which 
partially  shows  signs  of  fatty  degeneration.  Decayed  tubercles  are  inter- 
spersed. The  diffuse  type,  on  the  other  hand,  shows  the  synovial  membrane 
thickened  and  reddened,  its  solid  surface  being  covered  with  fibrinous  exuda- 
tion. This  hyperplastic  variety  generally  leads  to  the  formation  of  a  serous 
effusion  in  the  joint  (tuberculous  hydrops).  The  fibrin  may  deposit  itself 
also  in  the  recesses  of  the  joint,  where  it  may  become  organized.  The  mem- 
brane becomes  thickened;  at  the  deeper  edges  organized  fibrin  prolifer- 
ates and  covers  the  cartilage,  which  is  finally  invaded  and  macerated.  Thus 
the  cartilage  becomes  thinner,  and  finally  appears  sieve  shaped  at  some  por- 
tions. In  the  further  course  the  destruction  may  become  so  extensive  that 
only  small  remnants  of  the  cartilage  are  found  at  some  areas,  while  the  larger 
portion  of  the  joint  surface  is  occupied  by  newly  formed  tissue.  The  liga- 
ments, as  well  as  the  parasynovial  tissues,  share  the  same  fate.  They  swell 
and  become  softened,  so  that  with  the  surrounding  connective  tissue  they 
appear  like  soft  jelly.  This  swelling,  wliich  is  in  strong  contrast  to  the  atro- 
phy of  the  non-infected  part  of  the  extremity,  gives  the  joint  the  well- 
known  spindle  shape.  The  granulating  type  shows  vague  symptoms  at 
the  beginning;  later  there  is  uniform  thickening  of  the  joint,  serous  effusion, 
and  muscular  contraction.  In  this  stage,  of  course,  the  clinical  symptoms 
indicate  the  disease.  At  the  early  era  no  focus  exists  which  could  be  skia- 
graphed,  but  there  is  the  irregular  thickening  of  the  synovial  membrane, 
which  finds  its  skiagraphic  expression  in  the  irregular  joint  line  wliich,  at 
the  same  time,  appears  diffused,  cloudy,  and  often  shaggy.  In  the  fibrous 
form  the  shadows  are  darker.  If  the  process  of  destruction  reaches  the  car- 
tilage, its  erosion  is  indicated  by  its  saw-like  appearance.  If  the  cortex  is 
reached,  the  skiagraphic  impression  is  left  as  if  a  piece  had  been  bitten  out. 


THE   ROENTGEN-RAY   IN   EARLY   DIAGNOSIS. — BECK.  147 

The  invasion  of  the  periarticular  tissue  finds  its  skiagraphic  expression  in 
the  irregular  dark  shadows  which  prevail  in  contrast  to  the  light  shadows 
that  point  to  the  absorption  of  calcareous  matter  as  a  consequence  of  the 
inflammatory  reaction.  This  phenomenon  is  found,  to  a  greater  or  lesser 
extent,  in  all  cases  of  bone-  or  joint  tuberculosis,  some  areas  showing  it  more 
marked  than  others,  according  to  the  greater  or  lesser  intensity  of  the  pro- 
cess at  the  various  affected  zones.  If  there  is  hydrops,  the  joint  gap  be- 
comes enlarged  in  proportion  to  the  amount  of  distention  of  the  joint.  One 
condyle  becomes  hypertrophied,  sometimes  both.  Later,  when  there  is  no 
surgical  interference,  indentation  of  the  joint-line,  as  described  above, 
supei^venes. 

With  the  exception  of  the  hip-joint,  these  skiagraphic  points  apply  to 
all  joints.  The  special  anatomical  peculiarities  of  the  hip,  of  course,  cause 
special  skiagraphic  expressions.  Under  normal  circumstances  a  regular 
semicircular  arc,  as  the  expression  of  healthy  cartilage,  is  constantly  found 
between  the  femoral  head  and  the  acetabulum,  while  in  case  of  tuberculosis 
the  articular  outlines  become  slightly  irregular  and  diffuse,  sometimes  even 
translucent.  Later,  stalactite-shaped  projections  are  often  found  as  the 
expression  of  fungous  destructions  around  the  ruins  of  bone.  Of  course, 
when  the  destruction  has  advanced  so  far  that  the  head  becomes  severed, 
the  remnant  of  the  femoral  neck  being  displaced  upward,  the  diagnosis  can 
be  well  made  without  the  Roentgen  method.  But  in  modern  times  the  pro- 
cess of  destruction  should  not  be  permitted  to  go  as  far. 

Now,  how  are  these  skiagi'aphic  points  to  be  utilized  in  a  therapeutic 
sense?  I  may  say  that  in  the  type  of  tuberculosis  which  we  recognize  as 
the  osseous,  exposure  and  evidement  is  the  main  treatment,  while  synovial 
tuberculosis  is  amenable  to  more  conservative  therapy.  The  treatment  par 
excellence  in  these  cases  is  the  intra-articular  injection  of  iodoform  glycerin. 
It  is  a  surprising  fact  that,  in  spite  of  the  miraculous  results  reported  by  a 
number  of  trustworthy  surgeons,  this  method  has  not  become  popular. 
Some  claim  that  they  tried  in  vain  and  gave  it  up  therefore,  but  on  more 
thorough  inquiry  it  was  found  that  the  failures  were  due  to  its  injudicious  use, 
especially  in  the  osseous  type  or  in  cases  which  were  advanced  too  far.  Par- 
ticularly when  fistulae  had  formed,  when  there  is  periarticular  destruction, 
the  affected  area  should  be  widely  opened  and  the  diseased  synovials  and 
the  cheesy  and  necrotic  foci  extirpated.  No  injection  treatment  should  be 
tried  then.  It  is  also  in  such  cases  that  the  Roentgen  method  furnishes  a 
reliable  guide  during  the  operation  as  to  the  location  and  the  number  of  the 
foci  and  also  the  presence  of  necrotic  fragments. 


TREATMENT  OF  HIP-JOINT  DISEASE. 

By  Professor  F.  Calot, 

Berck  sur  Mer,  France. 


The  history  of  the  treatment  of  coxitis  inchides  three  epochs:  (1)  That 
in  which  abscesses  were  opened  and  drained — and  the  patient  died.  (2) 
That  in  which  such  tubercular  abscesses  were  aspirated  and,  if  they 
healed,  it  was  always  with  deformity  and  impaired  function.  (3)  The  pres- 
ent one,  consisting  in  the  early  intra-articular  injections  of  modifying 
liquids,  followed  by  cure,  complete  and  rapid,  with  no  lameness. 

The  shortening  of  the  leg,  consecutive  to  the  ordinary  treatment,  is  due  to 
the  erosion  and  destruction  of  the  articular  bone  surfaces,  under  the  tubercular 
process.  The  usual  therapy  is  unable  to  prevent  such  disgraceful  results, 
even  in  the  case  of  cure.  Through  a  very  long  experience  I  was  led  to  try 
a  treatment  preventive  of  such  destruction  of  the  articular  surfaces;  and 
such  a  preventive  is  found  in  the  early  injection  of  a  mixture  composed  of: 
Creosote,  3  parts;  iodoform,  7  parts;  ether,  25  parts;  olive  oil,  50  parts. 

Draw  a  horizontal  line  passing  by  the  spines  of  the  tubes,  and  locate  the 
femoral  artery.  Then  insert  a  long  and  thin  needle  (of  the  spinal  puncture 
type)  at  a  point  2  centimeters  outside  of  the  artery  and  3  centimeters  below 
the  horizontal  line.  At  4  or  5  centimeters  deep  the  point  of  the  needle  comes 
in  contact  with  the  anterior  surface  of  the  neck  of  the  femur.  Put  the  thigh 
in  slight  fiexion,  abduction,  outward  rotation.  Such  injections  to  be 
repeated  every  three  to  five  days, — 9  or  10  in  number, — and  covering  a 
space  of  some  two  months.  Quantity  of  liquid:  4  to  10  c.c,  according 
to  age.  All  this  time  the  patient  must  be  in  bed — either  with  extension 
or  in  a  plaster  cast.  The  cast  must  be  made  bivalve,  in  order  to  be 
removed. 

When  the  injection  period  is  over,  continued  extension  is  still  kept 
up,  or  the  plaster  cast,  for  a  second  period  of  tliree  months,  after  which 
four  to  five  months  are  spent  in  bed,  with  no  extension  or  plaster  cast, 
before  patient  is  allowed  to  get  up.  The  patient  will  then  be  cured.  Time 
and  experience  have  long  ago  proved  my  propositions.  The  cure  will  be 
effected  with  no  shortening  or  impairment  of  functions,  and  in  a  much 
shorter  time  than  under  earlier  methods. 

148 


SECTION  III. 
Surgery  and  Orthopedics  {Continued), 


FOURTH  DAY. 

Thursday,  October  1,  1908. 

TUBERCULOSIS  OF  THE  GENITO-URINARY  TRACT,  INTESTINES, 

AND  PERITONEUM. 


The  Section  was  called  to  order  by  the  President,  Dr.  Charles  H.  Mayo, 
at  half-past  nine  o'clock. 


TUBERCULOSIS  OF  THE  VAS,  EPIDIDYMIS,  AND 

TESTIS. 

By  John  B.  Walker,  M.D., 

New  York. 


Tuberculosis  of  the  testis  is  not  recognized  as  a  common  disease,  al- 
though it  occurs  more  frequently  than  is  generally  appreciated,  and  its 
ultimate  fatal  termination  is  due  to  this  lack  of  recognition  of  it  in  its  earliest 
stages.  It  is  of  the  greatest  importance  and  consideration  to  the  indi- 
vidual that  it  be  recognized  in  its  very  earliest  stages,  for  otherwise, 
if  not  thoroughly  treated,  it  is  generally  progressive  in  its  destruction  of 
first  one  testicle,  and  later  of  the  remaining  testicle.  Then  the  ascending 
process  involves  successively  the  vesicula)  seminales,  prostate,  bladder, 
or  kidney,  and  terminates  in  death. 

Heredity. — Heredity  is  not  of  much  importance  as  a  causative  agent,  as 
very  few  patients  give  any  family  history  of  tuberculosis.  It  may  act  as 
a  predisposing  cause  in  those  patients  who  have  inherited  a  condition  of 
lowered  vitality  in  which  there  is  a  tendency  to  the  development  of  tuber- 
culosis. It  may  also  have  some  influence  in  those  cases  developing  in  in- 
fancy. 

149 


150  SIXTH   INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

Etiology. — Age:  It  is  rare  in  infancy,  being  observed  only  occasionally 
in  large  children's  clinics.  However,  Julien  reports  16  cases  seen  in  children, 
among  whom  it  occurred  in  6  patients  under  one  year  of  age.  The  largest 
number  of  patients  are  seen  in  early  adult  life,  between  the  ages  of  twenty 
and  thirty,  when  the  sexual  organs  are  most  active.  Keyes  states  that  65 
per  cent,  occurred  between  the  ages  of  fifteen  and  thirty-four.  Tuber- 
culosis of  the  genital  system  occurs  usually  as  a  primary  disease  of  the  epididy- 
mis, and  is  not  generally  associated  with  pulmonary  tuberculosis.  In 
the  majority  of  cases  tuberculosis  of  the  epididymis  develops  before  there 
is  any  evidence  of  tuberculosis  elsewhere.  Keyes  states  that  among  100 
cases  where  the  histories  were  examined  by  him  he  found  49  cases  without 
any  evidence  of  previous  tuberculosis  elsewhere,  and  36  cases  who  had 
suffered  from  tuberculosis  elsewhere — in  the  lungs,  bones  and  joints,  glands, 
Iddneys,  etc.  Haas,  in  his  111  cases,  found  26  per  cent,  affected  with  tuber- 
culosis of  other  organs.  Various  observers  lay  different  degrees  of  stress 
upon  gonorrhea  as  a  causative  agent  in  developing  the  tuberculous  epididy- 
mitis. Koenig  believes  it  responsible  in  30  per  cent.,  while  Haas  states 
that  it  occurred  in  only  5  per  cent,  of  his  cases.  There  is  evidence  to  show 
that  gonorrhea  may  light  up  a  latent  tuberculous  focus  which  had  been 
dormant  for  years.  Trauma  is  held  to  be  of  importance  as  an  exciting  cause 
in  a  considerable  number  of  cases.  The  injury  may  have  been  slight  and 
forgotten  at  first,  but  later  the  patient  recalls  it  at  a  subsequent  exam- 
ination. 

The  tubercle  bacilli  enter  the  system  most  frequently  through  the 
respiratory  tract  or  the  gastro-intestinal  tract.  Bugge  claims  that  in  75 
per  cent,  of  all  persons  dying  from  all  causes  there  are  found  tubercle 
bacilli  present  in  the  mediastinal  or  mesenteric  glands.  From  the  glands 
the  tubercle  bacilli  enter  the  circulation.  Saltzman  afhrms  that  the  "bacilli 
contained  in  the  blood  localize  in  the  epididymis  at  some  point  where  there 
exists  a  focus  of  diminished  resistance,  congenital  or  produced  by  previous 
injury  or  disease.  The  frequent  localization  in  the  epididymis  is  accounted 
for  by  the  fact  that  the  spermatic  artery  divides  opposite  that  organ,  and 
that  the  vessels  of  the  epididymis  are  smaller  and  more  tortuous  than  those 
of  the  vas  or  testicle  proper,  the  current  therefore  being  slower."  Guyon, 
after  a  careful  study  of  the  histories  of  222  cases  and  42  autopsies,  concluded 
that  there  existed  a  primary  urinary  tuberculosis  as  well  as  a  primary 
genital  tuberculosis,  but  that  the  genital  organs  were  primarily  most  com- 
monly affected,  and  that  the  infection  most  often  ascended  from  the  genital 
tract  to  the  urinary  tract.  Koenig,  Kocher,  and  other  careful  observers 
have  maintained  that  in  the  majority  of  cases  the  testicular  affection  is 
preceded  by  tubercular  disease  higher  up  in  the  genito-urinary  tract,  especi- 
ally in  the  vesiculse  seminales  and  prostate. 


TUBERCULOSIS    OF    VAS,    EPIDIDYMIS,    AND   TESTIS. WALKER.  151 

A  descending  infection  is  not  considered  as  frequent  a  path  of 
invasion  as  tlirough  tlie  blood-vessels;  but,  of  course,  it  is  possible  as 
the  tubercular  process  displays  a  tendency  to  spread  along  the  natural 
passages  either  up  or  down,  and  to  induce  a  total  affection  of  the 
apparatus  involved.  In  order  to  substantiate  the  theory  of  a  descend- 
ing infection.  Belli  Santi,  in  his  experiments  on  dogs,  produced  a  tuber- 
culous epididymitis  by  injecting  tubercle  bacilli  into  the  urethra.  It 
was  necessary  to  produce  a  pathological  condition  by  ligating  the  sper- 
matic veins,  excluding  the  vas  and  producing  a  venous  stasis  in  the  organ. 
The  control  animals  not  injured  did  not  develop  tuberculosis.  Tubercle 
bacilli  were  found  also  in  the  testis,  but  the  testis  was  not  affected,  because 
the  natural  resistance  of  the  tissues  prevented  the  growth  of  the  germs. 
Von  Baumgarten,  working  to  demonstrate  the  theory  of  an  ascending  in- 
fection, was  unable  in  his  experiments  to  produce  tuberculosis  of  the  vas 
when  the  tubercle  bacilU  were  injected  into  the  prostatic  urethra  or  pros- 
tate, but  if  injected  into  the  testis,  tuberculosis  of  the  vas  regularly  followed; 
whereupon  von  Baumgarten  concluded  that  the  tubercle  bacilU  do  not 
travel  against  the  stream  of  blood  or  lymph  secretion.  Von  Baumgarten 
found  tuberculosis  limited  in  six  instances  to  the  vas  adjoining  the  epididymis, 
and  this  v/as  corroborated  by  microscopical  serial  sections  which  showed 
the  intensity  of  tuberculosis  diminishing  as  the  sections  progressed  toward 
the  prostate.  Finally,  the  fact  that  diffuse  tuberculosis  of  the  vas  is  more 
common  than  the  disseminated  is  also  favorable  to  the  teaching  of  ascend- 
ing tuberculosis;  and  where  disseminated  tuberculosis  existed,  those  nodes 
nearer  the  prostate  were  not  in  as  advanced  a  state  of  degeneration,  and 
clinically,  too,  there  was  an  appreciable  diminution  in  the  size  of  the  fusi- 
form nodules  from  the  testis  to  the  prostate.  ''Whereas  the  earlier  ob- 
servers regarded  tuberculosis  of  the  epididymis  a  resultant  of  descending 
tuberculosis,  the  weight  of  foremost  pathologists,  Virchow,  Rokitanslvy, 
Weigert,  aver  that  vas  deferens  tuberculosis  is  secondary  to  tuberculosis 
of  the  epididymis.  The  earlier  wrong  beUef  has  its  origin  in  post-mortems 
conducted  on  advanced  cases,  who  succumbed  to  their  tuberculosis;  the 
incipient  cases  were  not  studied.  Von  Bruns  (Haas),  from  the  study  of 
111  cases  operated  upon,  has  no  doubt  that  in  the  great  majority  of  cases 
epididymis  tuberculosis  preceded  disease  of  the  vas  deferens.  Acceptance 
of  this  overwhelming  proof  as  to  the  mode  of  dissemination  of  tuberculosis 
of  the  vas  is  responsible  for  very  high  excision."  Undoubtedly  one  can 
have  a  descending  infection,  yet  most  observers  believe  that  this  disease 
is  usually  an  ascending  infection,  the  epididymis  being  affected  primarily 
and  the  bladder,  prostate,  etc.,  secondarily,  the  process  extending  upward 
along  the  surface  of  the  mucous  membrane  of  the  excretory  duct. 

Reynier  favors  the  view  of  primary  involvement  of  the  epididymis, 


152  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

claiming  that  early  examination  will  demonstrate  it.  A  patient  dying 
of  a  fracture  of  the  slcull  showed  at  autopsy  early  tuberculosis  of  the  epididy- 
mis and  no  other  localization.  In  three  other  cases  of  tuberculosis  of  the 
epididymis,  after  careful  examination,  no  other  lesion  was  found.  Tillaux 
reports  a  similar  case  of  tuberculosis  of  the  epididymis  cured  by  vasectomy. 
Dimitresco  (1897),  after  a  careful  study  of  the  literature,  concluded  that 
"the  disease  may  begin  primarily  in  the  prostate,  vesiculae  seminales,  or  the 
epididymis,  the  latter  being  the  method  in  an  immense  majority  of  cases. 
The  testis  is  always  healthy  at  first,  except  in  rare  instances.  Young  says, 
'it  seems  to  me  sufficiently  proved  that  primary  tuberculosis  of  the  epididy- 
mis occurs,  and  probably  is  the  most  common  initial  lesion,'  though  it  cannot 
be  denied  that  involvement  of  the  epididymis  often  occurs  secondary  to 
disease  of  the  vesiculae  seminales  and  prostate,  as  it  does  less  frequently 
after  tuberculosis  of  the  lungs  and  of  the  urinary  tract." 

As  there  is  marked  divergence  of  opinion  as  to  the  location  of  the  primary 
focus,  so  there  is  also  great  diversity  of  opinion  as  to  the  method  of  extension. 
This  disease  most  often  occurs  first  in  the  right  testis.  The  infection  begins 
in  the  globus  minor,  extends  to  the  globus  major,  and  later  involves  the 
testis.  In  the  early  stages  one  or  more  small  nodules  may  be  found  in 
globus  minor  or  major;  "later  other  nodules  form  in  different  parts,  which 
enlarge  and  coalesce,  converting  the  epididymis  into  a  hard,  irregularly 
shaped  mass,  which  still  later,  after  caseation  and  softening  have  taken 
place,  may  be  soft  and  fluctuating."  As  the  disease  progresses  the  testis 
becomes  involved,  and  later  it  begins  to  ascend  and  infect  first  the  vas, 
not  throughout  its  entire  length,  but  at  various  points  irregularly  located; 
but  not  until  it  is  extensively  diseased  do  the  vesiculae  seminales  become 
infected.  After  this  the  prostate  becomes  somewhat  involved;  following 
this  the  opposite  testis  becomes  diseased  in  a  majority  of  the  cases,  tliis 
extension  being  due  to  the  flow  of  the  infectious  material  up  the  diseased 
vas  to  the  prostatic  urethra  and  down  the  opposite  vas  to  the  epididymis 
on  the  same  side. 

Symptoms. — Usually  the  onset  is  very  gradual,  the  first  symptom  ap- 
pearing insidiously  and  progressing  slowly.  If  the  patient  be  debilitated 
or  if  a  mixed  infection  exists,  the  onset  may  be  sudden  and  the  course  rapid 
and  violent.  The  course  is  generally  slower  in  children  than  in  adults, 
the  parents  first  noticing  a  slight  swelling  of  the  epididymis,  which  is  not 
especially  painful.  In  the  adult  there  occurs  usually  a  feeling  of  weight 
and  discomfort  in  the  testis,  which  first  becomes  tender  rather  than  painful 
on  pressure.  A  nodule  at  the  lower  part  of  the  epididymis  is  then  acciden- 
tally found  on  examination.  After  a  short  time  a  dull  acliing  pain  develops 
in  the  testis,  which  is  aggravated  by  exercise,  but  which  often  disappears 
entirely  when  the  patient  is  resting.     Later  this  pain  may  become  dull, 


TUBERCULOSIS   OF   VAS,    EPIDIDYMIS,    AND   TESTIS. WALKER.  153 

heavy,  aching,  and  extend  up  the  cord  to  the  groin  or  even  be  felt  in  the 
back.  The  nodule  becomes  larger  as  it  extends  up  the  epididymis,  then 
it  involves  the  testis,  and  later  extends  upward  along  the  vas,  the  prog- 
ress being  slow  or  rapid  according  to  the  condition  of  the  patient.  Fre- 
quently at  first  there  are  no  general  constitutional  symptoms  unless  there 
be  tuberculous  deposits  in  some  other  organ.  The  urethral  discharge 
which  is  generally  present  is  due  to  the  irritating  action  of  the  tuberculous 
products  which  are  discharged  into  the  prostatic  urethra.  It  may  be 
whitish  and  mucoid  or  bloody  and  purulent.  As  the  disease  advances  it 
produces  more  or  less  vesical  irritation.  At  first  there  is  merely  a  slight 
frequency  of  urination;  later  tenesmus  develops.  If  the  urine  be  examined, 
it  will  be  found  to  contain  a  small  amount  of  pus,  blood,  and  mucus.  Careful 
search  for  tubercle  bacilli  must  always  be  made  and  great  care  must  be  used 
to  differentiate  it  from  the  smegma  bacilH. 

In  many  cases  the  vesiculse  seminales  become  involved  and  are  found 
to  be  soft  and  swollen  and  somewhat  painful  on  pressure.  "Later  nodules 
develop  and  become  of  irregular  shape  and  are  hard  and  painful  on  pressure." 
If  the  prostate  becomes  involved,  it  is  somewhat  difficult  to  detect  it  in 
the  early  stages,  inasmuch  as  the  tuberculous  deposit  occurs  deep  in  the 
substance  of  the  prostate;  at  first  it  is  swollen  and  tender,  but  later  hard 
and  nodular.  As  the  disease  advances  the  nodules  in  the  epicUdymis  en- 
large, coalesce,  and  soften,  and  later  the  pus  burrows  into  the  adjacent 
tissues,  the  scrotal  sldn  becomes  adherent,  bluish,  and  finally  the  abscess 
opens  spontaneously  without  much  pain.  One  or  more  sinuses  are  formed 
which  show  no  tendency  to  close. 

A  hydrocele  is  almost  always  found  when  the  testis  becomes  involved. 
Careful  examination  will  also  frequently  reveal  the  presence  of  tuberculous 
lesions  in  other  parts  of  the  body — either  former  foci  or  present  active 
disease.  Unless  the  local  lesion  be  easily  removed,  the  opposite  testicle 
sooner  or  later  becomes  involved  in  a  large  majority  of  all  cases.  Haas 
states  that  "simultaneous  involvement  of  both  testes  is  rare,  only  about 
3  per  cent.,  but  that  in  38  per  cent,  the  opposite  testis  became  involved." 

Diagnosis. — Epididymitis  due  to  tuberculosis  may  often  be  confused  with 
that  due  to  gonorrhea  or  syphilis,  and  with  neoplasm.  If  due  to  tuberculosis, 
one  may  frequently  discover  a  history  of  recurrent  attacks,  or  may  find 
traces  of  other  tuberculous  foci,  enlarged  cervical  glands  in  childhood, 
or  see  the  scars  of  former  abscess  formation,  osteomyelitis,  hip-  or  knee- 
joint  trouble.  FamiHarity  with  clinical  aspects  of  tuberculosis  will  also 
help.  In  a  majority  of  cases  there  is  present  a  hydrocele  which  obscures 
the  free  and  perfect  examination,  so  this  must  be  aspirated  before  the 
epididymis  becomes  distinct  enough  to  feel.  The  tuberculin  test  may 
also  be  made  use  of.     Tubercle  bacilli  may  also  be  found  in  the  urine  or  in 


154  SIXTH   INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

pus  massaged  from  the  prostate  or  vesiculae  seminales.  The  nodules  are 
at  first  isolated  and  independent  of  each  other  and  not  confluent,  and  are 
of  peculiar  hardness.  They  also  extend  up  the  vas,  which  becomes  thickened 
and  nodular;  this  thickening  of  the  vas  is  absent  in  gonorrhea  or  syphilis. 
Vesical  irritation  is  present  in  tuberculosis,  but  not  present  in  syphilis. 
When  it  is  due  to  syphilis,  it  is  influenced  by  antisyphilitic  remedies  and 
disappears  under  treatment.  In  syphilis  are  found  specific  lesions  else- 
where, which  also  yield  to  treatment.  In  syphilis  no  tubercle  bacilli  are 
found  in  the  urine.  Sinuses  are  generally  present  in  tuberculosis,  but 
not  in  gonorrhea  or  syphilis. 

Prognosis. — ^This  varies  with  the  extent  and  severity  of  the  disease, 
and  depends  greatly  upon  the  method  of  treatment  employed.  In  some 
cases  the  disease  remains  local  for  a  long  period,  and  may  ultimately  cure 
itself  by  caseation  and  cicatrization.  Usually  the  disease  slowly  extends 
from  the  epididymis,  and  finally  involves  the  prostate,  vesiculoe  seminales, 
and  bladder,  so  that  the  prognosis  is  unfavorable  when  the  disease  is  left 
untreated.  "Whether  the  affection  of  the  vesiculse  seminales  or  prostate 
supersedes  or  follov\^s  the  testicular  disease  or  not,  the  clinical  fact  remains 
the  same.  The  removal  of  the  testis  and  epididymis  causes  in  a  large  per- 
centage of  the  cases  a  complete  subsidence  of  vesical  or  prostatic  symptoms 
and  healing  of  tubercular  process  in  these  parts."  "If  the  ejDididymis 
which  is  primarily  affected  be  removed  early,  it  is  probable  that  the  other 
testis  will  not  become  involved."  In  children  the  prognosis  is  usually 
good  if  palliative  treatment  be  employed. 

Treatment. — ^The  treatment  may  be  palliative  or  radical.  In  infancy 
tuberculous  disease  of  the  testis  and  epididymis  exhibits  a  tendency  to 
encapsulation  and  cure,  so  that  no  radical  operation  is  indicated.  Con- 
stitutional and  hygienic  remedies  should  be  employed.  The  testis  should 
be  supported  and  the  child  should  rest  as  much  as  possible.  If  an  abscess 
forms,  it  should  be  early  incised  and  curetted.  In  the  adult,  when  the  diag- 
nosis is  definite,  it  is  wiser  not  to  delay,  but  to  proceed  with  either  epididy- 
mectomy  or  orchidectomy.  General  hygienic  and  constitutional  treatment 
is,  of  course,  not  to  be  neglected,  but  to  be  combined  with  operative  procedure. 
Incision  and  curettage  must  be  considered  merely  as  palliative  measures, 
and  are  usually  followed  by  prolonged  suppuration,  with  extension  of  the 
disease  and  ultimate  destruction  of  the  testis.  Excision  of  the  vas,  as 
recommended  by  Mauclaire,  is  not  sufficiently  radical.  Finocchiaro  has 
recently  reported  some  excellent  cases  treated  after  Duranti's  method  with 
local  injections  of  iodin.  He  states  that  the  inflamed  epididymis  rapidly 
subsided  in  size  and  became  transformed  into  indolent  fibroid  tissue.  The 
iodin  stimulates  the  tissues  to  increased  resistance  and  phagocytosis,  while 
it  attenuates  the  virulence  of  the  bacteria.     The  iodin  treatment  restores 


TUBERCULOSIS   OF   VAS,    EPIDIDYMIS,    AND   TESTIS. — WALKER.  155 

to  society  men,  not  eunuchs.  Sufficient  time  has  not  yet  elapsed  to  recom- 
mend this  as  a  radical  treatment.  Avulsion,  as  advised  by  von  Biingner, 
has  been  followed  by  too  many  accidents  to  permit  it  to  be  recommended 
above  epididymectomy.  The  extent  of  the  disease  must  determine  wliich 
operation  is  to  be  followed.  In  all  cases  of  tuberculosis  of  the  epididymis 
which  are  recognized  early,  epididymectomy  is  the  operation  of  choice. 
It  was  first  employed  in  1850  by  Jarjavay.  Since  then  various  represent- 
ative surgeons  have  used  and  advised  it.  It  has  constantly  gained  in  favor 
as  a  conservative  operation. 

Oferation. — An  anatomical  dissection  is  made,  wliich  is  easy,  and  very 
little  cutting  is  necessary,  except  in  dividing  the  vasa  deferentia  where  they 
enter  the  globus  major.  "An  incision  is  made  into  the  sac  of  the  tunica 
vaginalis  just  external  and  parallel  to  the  epididymis."  A  dissection  is 
made  of  the  epididymis  from  the  testis  proper,  commencing  below  at  the 
globus  minor  and  passing  upward  to  the  mediastinum  testis.  From  here  one 
proceeds  slowly  and  carefully,  so  as  not  to  injure  the  spermatic  arteries 
and  veins,  closely  hugging  the  epididymis  and  separating  it  from  the  testis 
proper  and  the  spermatic  vessels.  Blunt  dissection  is  best  employed. 
When  the  globus  major  is  free,  the  vas  is  to  be  isolated  from  the  other 
structures  of  the  cord  upward  as  far  as  the  internal  ring;  it  is  clamped 
and  divided  and  cauterized  with  95  per  cent,  carbohc  acid;  the  needle 
is  worked  upward  in  the  lumen  half  an  inch;  when  the  cauterization  is 
complete,  the  vas  is  hgated  with  chromic  one-quarter  of  an  inch  from  the 
end,  and  the  tunica  albuginea  is  sutured  with  catgut.  The  testis  is  replaced 
in  the  sac  (scrotal).  The  external  ring  is  closed  with  catgut  and  with  a 
drain.  The  drain  is  removed  in  forty-eight  hours.  Epididymectomy 
should  be  performed  in  all  cases  of  localized  tuberculosis  of  the  epididymis, 
and  also  in  those  cases  where  only  small  areas  of  the  testis  are  involved. 
It  is  a  radical  method  because  it  removes  the  diseased  tissues,  and  an  economic 
procedure  because  it  preserves  the  testis.  It  becomes  feasible  because 
the  patient  will  consent  to  an  early  epididymectomy,  but  will  not  consent 
to,  but  postpones  until  too  late,  the  operation  of  castration.  Every  one 
to-day  acknowledges  the  great  necessity  of  preserving  the  testis,  because 
of  its  great  importance  in  supplying  the  internal  secretion  which  is  so  neces- 
sary for  the  body  economy  and  nerA'^ous  equilibrium.  After  epididymectomy 
the  testis  does  not  atrophy;  the  power  of  fecundation  is  lost,  but  the  desire 
for  and  the  power  of  coitus  are  preserved.  An  examination  of  the  literature, 
with  the  reports  of  more  than  200  cases,  by  such  competent  observers  as 
Keyes,  Young,  Haynes,  ^lurphy,  Berger,  Petit,  Rovsing,  Duranti,  Lauen- 
stein,  Bardenheuer,  and  others,  proves  beyond  doubt  that  epididymectomy 
is  preferable  to  orchidectomy,  except  as  when  contraindicated  by  extensive 
disease  of  the  testis.     Orchidectomy  should  be  limited  to  those  cases  of 


156  SIXTH    INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

extensive  disease  of  the  testis.  In  examining  the  pathological  reports  of 
numerous  specimens  after  castration,  it  has  been  found  that  the  glandular 
portion  of  the  testis  was  not  involved;  therefore  in  these  cases  orchidectomy 
was  not  indicated.     Furthermore,  sexual  power  has  been  lost. 

Results. — After  epididymectomy  and  orchidectomy  in  many  cases  the 
symptoms  of  vesical  and  prostatic  irritation  subside.  Reclus  states  that 
the  majority  of  cases  of  tuberculosis  of  the  testis  are  accompanied  by 
foci  in  the  prostate  and  seminal  vesicles,  and  that  these  patients  get  well 
after  orchidectomy.  Their  recovery  is  due  probably  to  the  fact  that  the 
constant  stream  of  virulent  products  from  th'^  diseased  epididymis  is  stopped 
and  the  irritation  of  the  prostate  and  adjacent  structures  ceases.  The  most 
convincing  statistics  are  those  of  Koenig.  In  45  carefully  examined  cases 
the  prostate  or  seminal  vesicles  were  involved  17  times,  with  disease  of  one 
testicle,  and  14  times  with  both  testicles.  Of  the  17  cases,  14  were  followed 
over  two  years  with  10  complete  cures,  1  improvement,  and  1  death.  Of 
the  14  cases,  9  were  cured,  2  improved,  and  2  died.  In  all  the  fatal  cases 
the  lungs  or  urinary  tract  were  involved  before  the  operation.  "It  is  there- 
fore well  established  that  tuberculosis  of  the  prostate  and  vesiculse  seminales 
not  only  does  not  contraindicate  operation,  but  in  the  majority  of  instances 
will  disappear  after  the  operation.  This  seems  to  follow  the  partial  oper- 
ation (epididymectomy)  as  well  as  castration"  (Young). 

Conclusions. — Castration  has  not  been  followed  by  the  brilliant  results 
expected  after  so  radical  an  operation.  It  should  be  limited  to  those  cases 
where  only  one  testis  is  extensively  diseased,  but  it  is  especially  objectionable 
when  both  testes  are  involved. 

Epididymectomy  is  preferable  to  castration  in  the  usual  form  of  tuber- 
culosis of  the  testis.  Cure  follows  in  the  majority  of  cases.  Inasmuch 
as  it  can  be  performed  under  cocain  anesthesia,  it  is  not  contraindicated 
when  there  is  involvement  of  the  lungs  or  the  kidneys.  After  epididymec- 
tomy the  testes  frequently  preserve  their  normal  macroscopical  appearance. 


BLASENTUBERKULOSE. 

Von  Dr.  Med.  Wilhelm  Karo, 

BerliQ. 


Indem  ich  fiir  die  ehrenvolle  Einladung  unseres  verehrten  Herm 
Vorsitzenden,  Ihnen  ein  Referat  iiber  Blasentuberkulose  zu  erstatten, 
verbindlichst  danke,  bemerke  ich,  dass  ich  bei  der  Kiii-ze  der  mir  zuge- 
messenen  Zeit  Ihnen  nur  in  grossen  Ziigen  meine  klinischen  Erfahningen 
ohne  Beriicksichtigimg  der  von  anderen  Autoren  publizierten  Anschauungen 
vortragen  kann.  Die  Basis  meiner  Ausfiihrungen  bildet  das  grosse  Material 
der  Casper'schen  Klinik  in  Berlin,  an  der  ich  in  den  letzen  7  Jahren  iiber  100 
Falle  von  Urogenitaltuberkulose  zu  beobachten  Gelegenheit  hatte.  Wir 
betrachten  die  Tuberkulose  der  Harnblase  als  Teilerscheinung,  resp.  als  ein 
Symptom  einer  tuberkiilosen  Infektion  des  Urogenitalsystems.  Hielt  man 
friiher  allgemein  die  Urogenitaltuberkulose  fiir  einen  aufsteigenden  Prozess, 
und  gait  demgemass  die  tuberlailose  Blase  und  noch  mehr  die  Nierentuber- 
kulose  als  eine  unheillDare  Krankheit,  so  lehren  uns  unsere  chirurgischen 
Erfolge,  dass  die  Blase  fast  stets  descendierend  von  der  auf  hiimatogenem 
Wege  primar  erkrankten  Niere  aus  infiziert  wird;  in  seltenen  Fallen  mag  die 
Blasentuberkulose  durch  Ubergreifen  eines  primar  in  den  Genitalorganen 
lokalisierten  Herdes  entstanden  sein. 

Die  Frage,  ob  es  iiberhaupt  eine  primare  Blasentuberkulose  ohne  Beteili- 
gung  der  Nieren  gibt,  lasst  sich  klinisch  ohne  Autopsie  in  vivo  kaum  entschei- 
den.  Da,  wie  wir  durch  das  Studium  der  Nierentuberkulose  gelernt  haben, 
trotz  klaren,  eiweissfreien  Harns  eine  Tuberkulose  in  einer  Niere  zu  bestehen 
vermag,  wird  uns  selbst  der  doppelseitige  Ureterenkatheterismus  nur  be- 
dingten  Aufschluss  geben  konnen.  Indcssen  hat  uns  das  Ureterencystoskop 
dariiber  belehrt,  dass  fast  in  alien  Fallen  von  tuberkuloser  Pyurie  der  Eiter 
bereits  aus  den  Nieren  kommt,  dass  es  also  Blasentuberkulose  ohne  Beteili- 
gung  der  Nieren  kaum  je  gibt.  So  befinden  sich  unter  unserem  grossen 
Material  lediglich  zwei  Fiille,  in  denen  der  einzige  erkennbare  Tuberkel- 
bazillenherd  die  Blase  war;  beide  betrafen  Frauen,  in  beiden  Fallen  wurde 
durch  doppelseitigcn  Ureterenkatheterismus  aus  beiden  Nieren  klarer 
albumenfreier  Harn  ohne  korperliche  Bestandteile  entleert.  Da  wir  aber 
wie  ebcn  ausgefiihrt,  hieraus  noch  nicht  auf  Intaktheit  der  Nieren  schliessen 
diirfen,  muss  ich  die  Frage,  ob  auch  in  diescn  beiden  Fallen  die  Tuber- 

157 


158  SIXTH   INTERNATIONAL   CONGRESS    ON   TUBERCULOSIS. 

kulose  nicht  etwa  urspriinglich  in  cler  Niere  begonnen,  und  erst  sekundar 
die  Blase  ergriffen  habe,  unentschieden  lassen.  Massgebend  fiir  unsere 
Frage  waren  nur  solche  Falle,  in  denen  bei  Idarem  Harn  auch  die  modernen 
functionellen  Untersuchungsmethoden  die  Intaktheit  der  Nieren  bewiesen 
hatten.  Die  eben  angefiihrten  Falle — sie  liegen  bereits  5  Jahre  zuriick — 
wurden  functionell  nicht  untersucht.  Daher  mochte  ich  auf  Grund  meiner 
langjahrigen  Erfahrungen  betonen,  dass  ich  keinen  einzigen  Fall  kenne,  in 
dem  der  absolut  zwingende  Beweis  fiir  das  Vorkommen  einer  primaren 
isolierten  Blasentuberkulose  erbracht  ist. 

Pathologisch-anatomisch  unterscheiden  wir  zwischen  der  eigentlichen 
Blasentuberkulose,  die  bekanntlich  mit  der  Genese  und  Entwickelung  des 
miliaren  Tuberkels  gleichen  Schritt  hillt,  und  der  tuberkulosen  Cystitis. 
Vom  klinischen  Standpunkt  aus  hat  die  Lokalisation  dieser  Veranderungen 
ein  grosses  Interesse;  denn  namentlich  in  frischen  Fallen  gibt  sie  uns  einen 
Aufschluss  iiber  den  Infektionsweg,  also  beispielsweise  bei  einer  deszen- 
dierenden  Tuberkulose  der  rechten  Niere  findet  man  in  der  Regel  in  der 
Umgebung  des  rechten  Ureters  die  charakteristischen  Veranderungen. 
Dass  auch  hier  Ausnahmen  vorkommen,  soil  welter  unten  ausgefiihrt  werden. 
Je  langer  die  Krankheit  besteht,  um  so  mehr  verwischt  sich  die  urspriing- 
liche  Lokalisation,  desto  weitere  Partien  der  Blase  werden  von  der  Krank- 
heit ergriffen. 

Was  nun  die  Symptome  der  Blasentuberkulose  anbelangt,  so  brauchen 
dieselben  nicht  nennenswert  verschieden  zu  sein  von  den  auch  bei  anderen 
Formen  der  Cystitis  landlaufigen,  also  Dysurie  in  den  mannigfachsten  Ab- 
stufungen,  Pyurie  und  Hamaturie.  Es  kann  nicht  scharf  genug  betont 
werden,  dass  jedes  einzelne  dieser  Symptome,  sofern  es  von  mehr  als  vor- 
iibergehender  Erscheinung  ist,  uns  an  Tuberkulose  der  Harnwege  denken 
lassen  muss.  Es  hat  sich  als  verhangnisvoller  Irrtum  herausgestellt,  sich 
durch  die  kraftige  Konstitution  des  Kranken,  durch  sein  bliihendes  Aussehen, 
durch  Korpergewichtszunahme  tauschen  zu  lassen,  und  in  solchen  Fallen 
die  Harnveranderung  als  Symptom  einer  einfachen  Cystitis  anzusehen. 
Als  Illustration  hierzu  ein  Fall : 

Ein  56-jahriger  Mann  erkrankte  ein  Jahr  bevor  er  in  unsere  Behandlung 
trat,  an  einer  Gonorrhoe,  die  unter  der  iiblichen  Behandlung  allmahlich 
mit  Hinterlassung  eines  als  chronische  Cystitis  gedeuteten  Symptomen- 
komplexes  ausheilte.  Patient  musste  haufig  urinieren;  der  Harn  blieb 
trotz  standiger  Blasenspulungen  eitrig,  die  Beschwerden  wurden  von  Monat 
zu  Monat  schlimmer,  olme  dass  Patient  bis  auf  den  lastigen  qualenden 
Harndrang — er  musste  schliesslich  alle  20  Minuten  Urin  lassen — den  Ein- 
druck  eines  Schwerkranken  machte.  Als  er  in  unsere  Behandlung  trat, 
war  er  bei  bestem  Allgemeinbefinden.  Cystoskopisch  fanden  wir  den 
linken  Teil  der  Blase  stark  ulceriert,  den  linken  Ureter  zerkliiftet,  in  seiner 
Umgebung   bulloses    Oedem;   den    rechten    Teil   der    Blase   vollkommen 


BLASENTUBERKULOSE. KARO.  159 

gesund,  den  rechten  Ureter  klein,  mit  glatten  Eandern.  Der  Ureteren- 
katheterismus  ergab  links  eitrigen  Urin  mit  Tuberkelbazillen,  rechts  klaren 
Harn  ohne  korperliche  Bestandteile.  Die  linke  Niere  wurde  entfernt; 
wir  fanden  eine  grosse  tuberlvulose  Caverne  in  ilir.  Patient  erholte  sich  sehr 
rasch.  Bereits  zwei  Wochen  nach  der  Operation  horten  ohne  weitere 
lokale  Behandlung  die  Tenesmen  auf;  nach  4  Wochen  war  der  Urin  voll- 
kommen  klar.  Ich  habe  den  Patienten  noch  ioirz  vor  meiner  Abreise  vor 
wenigen  Wochen  wieder  gesehen.  Er  hat  seit  der  vor  4  Jahren  vorgenom- 
menen  Operation  20  Pfund  zugenommen;  sein  Harnist  auch  heute  noch 
absolut  klar;  die  Blase  cystoskopisch  voUkommen  ausgeheilt. 

Ich  habe  Ihnen  den  Fall  lediglich  als  eine  Illustration  zu  meiner  Be- 
hauptung  angefiihrt,  dass  man  sich  nicht  durch  den  guten  Allgemeinzustand 
des  Kranken  iiber  die  wirkliche  Ursache  seiner  Beschwerden  tauschen  lassen 
soil.  Vielmehr  mtissen  wir  in  alien  Fallen  von  Pyurie  an  Tuberkulose  der 
Urogenitalorgane  denken  und  nach  Tuberkelbazillen  fahnden.  Wir  haben 
gefunden,  dass  man  bei  geniigender  Geduld  in  mehr  als  90  %  der  Falle  schon 
im  einfach  gefarbten  Praparat  die  Bazillen  nachweisen  kann.  Zweckmas- 
sigerweise  zentrifugiert  man  den  Bodensatz  der  ganzen  24-stundigen  Harn- 
menge.  Eine  Verwechselung  mit  Smegma-Bazillen  darf  einem  geiibten 
Untersucher  nicht  passieren;  beide  Arten  unterscheiden  sich  durch  ihre 
Form,  wie  namentlich  auch  durch  die  Lagerung  im  Praparat.  Finden  wir 
keine  Bazillen,  dann  miissen  w4r  das  Tierexperiment  anstellen  und  zwar 
bedienen  wir  uns  zweckmassigerweise  des  nach  Bloch  modifizierten  Ver- 
fahrens,  das  uns  bereits  nach  etwa  10  bis  14  Tagen  zum  Ziele  fiihrt.  Der 
Sicherheit  halber  impfen  wif  gleichzeitig  ein  zweites  Meerschweinchen  ohne 
Quetschung  der  Driisen  nach  Bloch.  Der  negative  Ausfall  des  Tierexperi- 
ments  ist  noch  kein  zwingender  Beweis  fiir  die  nicht-tuberkulose  Natur  des 
Leidens.  Wir  miissen  in  solchen  Fallen  mit  der  Moglichkeit  einer  soge- 
nannten  geschlossenen  tuberkulosen  Pyonephrose  denken,  das  sind  Falle 
von  einseitiger  Nierentuberkulose  mit  Obliteration  des  kranken  Ureters, 
der  aus  der  Blase  entleerte  Harn  stammt  nur  aus  der  gesunclen  Niere. 
Wie  dem  auch  sei,  mag  man  Bazillen  gefunden  haben  oder  nicht,  stets  ist 
es  unsere  Pflicht,  in  jedem  Fall  von  Verdacht  auf  Tuberkulose  der  Harnwege 
durch  das  Cystoskop  unsere  Diagnose  zu  verfeinern.  Ich  scheue  mich  nicht, 
die  Unterlassung  der  Cystoskopie  in  solchen  Fallen  als  einen  groben,  ver- 
hangnisvollen  Kunstfehler  zu  bezeichnen,  muss  aber  gleich  hinzufiigen,  dass 
diese  Untersuchungen  nur  mit  peinlichster  Gewissenhaftigkeit,  mit  der 
grossten  Zartheit  vorgenommen  werden  diirfen,  weil  sie,  von  ungescliickter 
Hand  ausgefiihrt,  oft  von  bedenklichen  Folgen  begleitet  sein  konnen. 
Prinzipiell  empfiehlt  sich  vor  jeder  Cystoskopie,  die  Blase  mittels  Novokain 
oder  Alypin  eventuell  in  Verbindung  mit  Adrenalin  griindlich  zu  anasthe- 
sieren,  weil  wir  auf  diese  Weise  die  gerade  bei  Tuberkulose  so  charakteris- 
tische   Schmerzhaftigkeit  ausschalten,   und  dadurch   die   Blase   besser  zu 


160  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

entfalten  vermogen.  In  sehr  vorgeschrittenen  Fallen  von  tuberkuloser 
Schrumpfblase  ist  es  oft  zunachst  nicht  moglich,  die  Blase  zur  Cystoskopie 
geniigend  auszudehnen.  In  solchen  Fallen  miissen  die  Patienten  mit 
Dauerkatheter  und  schwachen  Sublimatspiilungen  eventuell  mit  Tuber- 
kulin  einige  Wochen  vorbehandelt  werden,  dann  gelingt  es  fast  stets,  unter 
lokaler,  resp.  unter  Riickenmarksanasthesie  eine  Cystoskopie  auszufiihren. 
Es  geniigen  uns  schon  50  bis  60  c.c.  Blaseninhalt. 

Was  sehen  wir  nun  mit  dem  Cystoskop?  Gemass  der  Pathogenese  der 
Blasentuberkulose  sehen  wir  an  den  Ureteren  in  ihrer  Form  und  Intensitat 
wechselnde  Veranderungen  von  einfachen  eitrigen  Auflagerungen  und  Rot- 
ungen  bis  zu  schweren  ulcerosen  Zerkliiftungen.  Dazu  gesellt  sich  meistens 
ein  mehr  oder  minder  diffuses  bulloses  Oedem,  das  oft  die  Uretermiindung 
iiberlagert.  Je  welter  vorgeschritten  der  Fall,  desto  grossere  Telle  des 
Trigonums  schwellen  samtartig  an  und  ulcerieren.  Die  vordere,  resp. 
obere  Wand  der  Blase  bleibt  meistens  verschont.  Ebenso  ist  der  Sphincter 
internus  kaum  je  von  dem  Krankheitsprozess  ergriffen,  also  ein  weiterer 
Beweis  gegen  die  Theorie  von  der  aufsteigenden  Tuberkulose.  Unter  den 
vielen  hunderten  von  Cystoskopien,  die  wir  in  Fallen  von  Urogenitaltuber- 
kulose  vorgenommen  haben,  fanden  wir  nur  ein  einziges  Mai  eine  hoch- 
gradige  Infiltration  des  Blasenhalses.  Gleichzeitig  bestand  in  diesem  Falle 
eine  so  hochgradige  Schrumpfung  des  TrigonumS;  dass  beide  Ureteren- 
offnungen  dicht  an  einander  geriickt  waren,  so  dass  man  sie  in  einem  Gesichts- 
felde  des  Cystoskops  beobachten  konnte.  Der  Befund  von  grauen  Knot- 
chen  von  scheinbaren  miliaren  Tuberkeln  in  der  Umgebung  der  Ureter- 
papille  bei  sonst  gesunder  Blase  ist  fiir  Tuberkulose  nicht  beweisend.  Wir 
haben  an  unsere  Klinik  solche  Falle  beobachtet  und  uns  selbst  tauschen 
lassen.  So  diagnostizierten  wir  bei  einem  3o-jahrigen  Geistlichen,  der  seit 
ca.  einem  Jahre  an  einer  unmotivierten  Pyurie  litt,  der  sehr  heruntergekom- 
men  war,  auf  Grund  des  cystoskopischen  Bildes — man  fand  um  den  rechten 
Ureter  typische  graue  Knotchen — eine  Tuberkulose  der  rechten  Niere.  Die 
Operation  ergab  eine  Steinniere,  doch  keine  Tuberkulose.  Weiterhin  ist 
gesundes  Aussehen  eines  Ureterostiums  und  seiner  Umgebung  kein  Beweis 
fiir  die  Intaktheit  der  betreffenden  Niere;  es  ware  fiir  den  Kranken  sehr 
verhangnis  wiirden  ^vir  auf  Grund  solcher  Befunde  unsere  therapeuvoll, 
tischen  Entschliessungen  treffen.     Dafiir  ein  belehrendes  Beispiel: 

Bei  der  Cystoskopie  eines  jungen  Madchens,  das  uns  mit  den  Schul- 
symptomen  einer  Tuberkulose  der  Harnwege  konsultierte,  fanden  wir  eine 
Auflockerung  und  Schwellung  des  linken  Ureters.  In  seiner  Umgebung 
einige  unbedeutende  Ulcerationen;  der  rechte  Ureter  war  intakt,  der  rechte 
Teil  der  Blase  gesund.  Wir  glaubten  also  auf  Grund  des  cystoskopischen 
Bildes  eine  Tuberkulose  der  linken  Niere  anzunehmen,  hielten  die  rechte 
Niere  fiir  gesund,  und  den  Fall  dementsprechend  fiir  operabel.     Der  doppel- 


BLASENTUBERKULOSE. — KARO.  '  161 

seitige  Ureterenkatheterismus  ergab  indessen  zu  unserer  grossten  Uberra- 
schung,  class  auch  die  rechte  Niere  eitrigen  bazillenhaltigen  Harn  entleerte, 
ja  in  ihrer  Funktion  so  schwer  geschadigt  war,  dass  wir  den  Fall  als  inoper- 
abel  entlassen  mussten. 

Ahnliche  Falle  sind  ims  auch  in  der  Folgezeit  gelegentlich  begegnet. 
Daraus  ergibt  sich  fiir  uns  die  absolute  Notwendigkeit,  in  jedem 
Falle  von  Tuberkulose  der  Harnwege  unbedingt  den  doppelseitigen 
Ureterenkatheterismus  behufs  genauer  Diagnose  auszufiihren,  Ja,  noch 
mehr!  Um  auch  bei  klarem  Harn  von  beiden  Seiten  vor  Irrtiimern 
geschiitzt  zu  sein,  miissen  wdr  die  modernen  funktionellen  Untersuchungs- 
methoden  zu  Rate  ziehen;  dieselben  sind  namentlich  auch  dann  von 
ausschlaggebender  Bedeutung,  wenn  beide  Nieren  eitrigen  Harn  sezernieren. 

Wenn  wir  auf  diese  Weise  rechtzeitig  jeden  suspekten  Fall  von  Uro- 
genitaltuberkulose  gi'iindlichst  untersuchen,  werden  wir  am  sichersten  einer 
Blasentuberkulose  vorbeugen;  es  wird  uns  dann  gelingen,  die  kranke  Niere 
zu  exstirpieren  zu  einer  Zeit,  wo  der  Krankheitsprozess  noch  auf  dieses  eine 
Organ  beschrankt  ist,  ohne  auch  in  der  Blase  Yeranderungen  hervorgerufen 
zu  haben.  Je  sorgfaltiger  ein  Arzt  seine  Kranken  zu  examinieren  versteht, 
je  gewissenh after  er  auf  jedes  scheinbar  noch  so  unwichtige  tSymptom  achtet, 
um  so  seltener  wird  ihm  eine  beginnende  Nierentuberkulose  entgehen.  Ich 
mochte  in  diesem  Zusammenhange  nochmals  auf  die  Beachtung  jeder  auch 
noch  so  voriibergehenden  Hamaturie  hinweisen.  Kommt  der  Patient  erst 
zu  einer  Zeit,  wo  die  Blasentuberkulose  mit  ihren  subjektiven  Beschwerden 
bereits  im  Vordergrunde  des  Krankheitsbildes  steht,  dann  hangt  die  Prog- 
nose derselben  davon  ab,  ob  es  noch  moglich  ist,  den  primaren  Krankheits- 
herd,  also  in  der  Regel  die  primar  erkrankte  Niere,  radikal  zu  entfernen. 
Ist  die  andere  Niere  gesund,  oder  wenigstens  noch  funktionstiichtig,  dann 
muss  selbst  bei  weit  vorgeschrittener  Blasentuberkulose  die  tuberkulose 
Niere  baldigst  entfernt  werden.  Wir  haben  uns  immer  und  immer  wieder 
iiberzeugt,  dass  durch  diese  Operation  selbst  sehr  vorgeschrittene  Falle  von 
tuberkuloser  Schrumpfblase  ohne  jede  weitere  lokale  Behandlung  ausheilen. 
Meist  lassen  bereits  wenige  Tage  nach  der  Nephrektomie  die  Miktionsbe- 
schwerden  nach ;  der  Urin  klart  sich  in  wenigen  Wochen — die  Pause  z wischen 
den  Miktionen  wird  von  Woche  zu  Woche  grosser.  Daher  hat  sich  uns  eine 
eigentliche  Behandlung  der  Blasentuberkulose  in  der  Mehrzahl  der  Falle  als 
iiberfliissig  erwiesen.  Neuerdings  unterstiitzen  wir  die  natiirliche  Heilungs- 
tendenz  der  Blasentuberkulose  nach  der  Nephrektomie  durch  eine  systema- 
tische  Tuberkulinkur.  Wir  richten  uns  nach  den  von  Holdheim  angege- 
benen  Vorschriften  und  beginnen  mit  einer  subcutanen  Injektion  von 
0.0025  mg.  Alttuberkulin.  Die  Dosis  wird  jedes  Mai  gesteigert,  die  Ein- 
spritzung  etwa  jeden  dritten  Tag  vorgenommen.     Unter  dieser  Kur  heilt 

VOL.   II — 6 


162  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

die  Blasentuberkulose  entschieden  schneller  als  in  den  nicht  mit  Tuberkulin 
nachbehandelten  Fallen.  Irgendwelche  Storungcn  durch  das  Tuberkulin 
haben  wir  niemals  beobachtet.  Von  den  vielen  chemischen  Mitteln,  die 
fiir  die  lokale  Behandlung  der  Blasentuberkulose  empfohlen  worden  sind, 
hat  sich  uns  immer  und  immer  wieder  das  Sublimat  als  das  brauchbarste 
bewiesen.  Wir  verwenden  dasselbe  in  ganz  schwachen  Losungen.  Wir 
beginnen  mit  1  :  10,000,  steigen  allraahlich  bis  zu  1  :  3000.  Durch  diinnen 
geknopften  Katheter  injizieren  wir  nach  vorheriger  vorsichtiger  Spiilung  der 
Blase  etwa  20  bis  50  c.c.  Sublimatlosung.  Jede  Dehnung  der  Blase  wird 
sorgfaltigst  vermieden.  Durch  Sitzbader  und  ]\Iorphium  werden  die  durch 
das  Medikament  gelegentlich  bedingten  Schmerzen  bckampft.  Hollander 
empfiehlt  das  Sublimat  gewissermassen  in  statu  nascendo  zu  geben.  Es 
geschieht,  indem  der  Patient  innerlich  lodkali  nimmt  und  man  in  die  Blase 
Calomel  injiziert.  Wir  haben  in  einigen  Fallen  dieses  Verfahren  angewandt. 
Es  ist  wesentlich  schmerzhafter  als  die  gewohnliche  Sublimatbehandlung, 
ohne  indessen  wirksamer  zu  sein.  Weiterhin  haben  wir  Wasserstoffsuper- 
oxyd  versucht,  sowie  auch  die  von  Rovsing  angegebene  Karbolbehandlung. 
Vor  letzterer  mochte  ich  Sie  auf  Grund  unserer  Erf  ahrungen  eindringlichst 
warnen.  Wir  bekamen  in  einem  Falle  so  stiirmische  schwere  Nachwirkungen, 
die  den  Kranken  wochenlang  in  einen  bedauernswerten  Zustandversetzten, 
dass  wir  nicht  mehr  den  Mut  haben,  das  Mittel  weiterhin  anzuwenden. 

Zum  Schluss  noch  ein  Wort  liber  die  direkte  chirurgische  Behandlung 
der  Blasentuberkulose.  Also  sectio  alta  oder  perinealis  mit  Auskratzung, 
resp.  Ausschneidung  der  Schleimhaut.  Friiher,  als  man  die  Blasentuber- 
kulose fiir  eine  aufsteigende  Krankheit  hielt,  wurde  sie  gelegentlich  versucht. 
Ihr  Erfolg  war  wohl  stets  negativ.  Heutzutage  diirfte  dieser  Eingriff  ent- 
sprechend  unserer  modernen  Anschauung  von  der  Pathogenese  der  Blasen- 
tuberkulose von  jedem  gewissenhaften  Arzte  verpont  werden.  Denn  in  den 
wenigen  schweren  qualvollen  Fallen  von  Blasentuberkulose,  die  so  spat  in 
Behandlung  kommen,  dass  die  Entfernung  der  Niere  nicht  mehr  moglich  ist, 
oder  bei  denen  nach  Entfernung  der  einen  Niere  auch  die  andere  tuber kulos 
erki'ankt  und  deshalb  die  Blase  nicht  zur  Ausheilung  kommen  kann,  wird 
man  besser  durch  Narcotica  die  Qualen  des  Kranken  mildern  als  sein  Siechtura 
durch  eine  in  ihren  Folgen  unberechenbare  Operation  noch  zu  vergrossern. 


Tuberculosis  of  the  Bladder. — (Karo.) 
Tuberculosis  of  the  bladder  is  almost  always  a  descending  process  of 

hematogenous  origin,  as  a  rule  the  result  of  renal  or  genital  tuberculosis. 
Pathologically  a  distinction  must  be  made  between  genuine  bladder 

tuberculosis  and  tuberculous  cystitis.    The  seat  of  the  morbid  changes 


BLASENTUBERKULOSE. — KARO.  163 

in  the  bladder  usually  depends  on  the  mode  of  infection;  thus  in  a  case 
of  right-sided  renal  tuberculosis  the  lesion  is  near  the  right  ureter. 

The  chief  symptoms  of  bladder  tuberculosis  are  difficult  micturition, 
hematuria  and  pyuria.  The  diagnosis  must  be  confirmed  by  finding  the 
tubercle  bacilli,  either  directly  in  the  preparation  or  by  animal  inocular 
tion. 

In  every  case  of  uro-genital  tuberculosis  the  primary  seat  of  the  tubercu- 
lous infection  must  be  determined  as  soon  as  possible  by  cystoscopy  or 
catheterization  of  the  ureters. 

The  cystoscopic  picture  is  not  in  itself  absolutely  characteristic  of 
tuberculosis.     Nodules  are  also  found  in  non-tuberculous  disease. 

The  surest  prophylactic  measure  to  prevent  tuberculosis  of  the  blad- 
der is  early  extirpation  of  the  diseased  kidney  before  involvement  of 
the  bladder  has  taken  place;  hence  the  prognosis  of  bladder  disease 
depends  on  whether  the  case  is  operable  or  not. 

In  the  great  majority  of  cases  spontaneous  recovery  of  the  bladder 
follows  removal  of  the  primarily  diseased  kidney.  If  the  bladder  does 
not  clear  up,  it  is  often  because  the  other  kidney  is  also  involved. 

The  most  suitable  treatment  of  cases  of  this  kind  is  a  systematic  tuber- 
culin-cure, supplemented  by  local  treatment  of  the  bladder  with  a  weak 
bichlorid  solution. 

Direct  surgical  treatment  of  a  tuberculous  bladder  is  of  no  avail  and  is 
therefore  to  be  deprecated. 


Tuberculosis  de  la  Vejiga. — (KLiro.) 

El  lugar  de  los  cambios  morbidos  en  la  vejiga  por  lo  general  depende  del 
modo  de  infeccion;  asi  pues  en  el  caso  de  afeccion  tuberculosa  del  rinon  del 
lado  derecho  la  lesion  esta  cerca  del  ureter  derecho. 

Los  sintomas  principales  de  la  tuberculosis  de  la  vejiga  son:  frecuencia 
de  miccion,  hematuria  y  piuria.  El  cUagnostico  debe  ser  confirmado  por  la 
presencia  del  bacilo  de  la  tuberculosis  al  examen  directo  de  la  preparacion, 
6  por  inoculaciones  en  los  animales. 

En  cada  caso  de  la  tuberculosis  uro-genital,  el  lugar  primero  de  la  infec- 
cion debe  buscarse  por  medio  del  cistoscopio  6  la  cateterizacion  de  los  ur6- 
teres.  El  cuadro  cistoscopico  no  es  por  si  solo  absolutamente  carac- 
tcristfco  de  la  tuberculosis.  Pequenos  nudos  y  promincncia  en  afecciones 
no  tuberculosas.  La  medida  profilactica  mas  segura  para  prevenir  la 
tuberculosis  de  la  vejiga,  es  la  extirpacion  del  rinon  afectado  antes  que 
este  haya  producido  una  afeccion  de  la  vejiga:  por  lo  tantoel  pronostico  de 
la  enfermedad  de  la  vejiga  depende  del  caso  si  este  es  operable  6  no  lo  es. 
En  la  mayor  parte  de  los  casos  una  cura  espontanea  se  observa  despu6s  de 


164  SIXTH  INTERNATIONAL  CONGRESS  ON  TUBERCULOSIS. 

la  nefrotomia  del  rinon  primeramente  afectado.  Si  no  se  observa  mejoria, 
esto  es  debido  a  que  el  otro  rinon  esta  tambien  afectado.  El  tratamiento 
mas  apropriado  para  esta  clase  de  casos  es  la  cura  sistematica  por  medio 
de  la  tuberculina,  acompanada  del  tratamiento  local  de  la  vejiga  por  medio 
de  las  soluciones  diluidas  de  bicloruro  de  mercurio.  El  tratamiento 
quirurgico  no  es  recomendable. 


Tuber culose  de  la  Vessie. — (Karo.) 

Le  si^ge  des  changements  morbides  dans  la  vessie  releve  ordinairement 
du  mode  d'infection;  par  exemple  dans  le  cas  de  tuberculose  r^nale  du  c6t6 
droit  la  lesion  est  pres  de  I'uretere  droit. 

Les  principaux  symptomes  de  la  tuberculose  de  la  vessie  sont  une  mic- 
turition difficile,  I'hematurie  et  la  pyurie.  Le  diagnostic  doit  etre  confirme 
par  la  decouverte  du  bacille  tuberculeux,  soit  directement  dans  la  prepara- 
tion, soit  par  inoculation  animale. 

Dans  tons  les  cas  de  tuberculose  uro-genitale  le  siege  primaire  de  I'in- 
fection  tuberculeuse  doit  etre  determine  aussitot  que  possible  par  la  cysto- 
scopie  ou  la  catheterisation  des  ureteres. 

L'image  cystoscopique  n'est  pas  en  elle-meme  absolument  caracteris- 
tique  de  la  tuberculose.  On  trouve  aussi  des  nodules  dans  des  maladies 
non  tuberculeuses. 

Le  moyen  prophylactique  le  plus  sur  pour  empecher  la  tuberculose  de 
la  vessie,  c'est  de  se  hater  d'extirper  le  rein  malade  avant  que  I'infection  n'ait 
envahi  la  vessie;  de  sorte  que  le  pronostic  de  la  maladie  de  la  vessie  depend 
de  cette  question:  est-ce  un  cas  operable  ou  non? 

Dans  la  grande  majorite  des  cas,  la  guerison  spontanee  de  la  vessie  suit 
I'excision  du  rein  premierement  affecte.  Si  la  vessie  ne  se  nettoie  pas, 
cela  vient  souvent  de  ce  que  I'autre  rein  est  aussi  infecte. 

Le  meilleur  traitement  des  cas  de  cette  espece  est  une  cure  syst^matique 
a  la  tuberculine,  supplementee  par  un  traitement  local  de  la  vessie  avec 
une  faible  solution  de  bichlorure. 

Le  traitement  chirurgical  direct  de  la  vessie  n'offre  aucun  resultat. 


TUBERCULOSIS  OF  THE  BLADDER. 

By  Bransford  Lewis,  M.D., 

St.  Louis. 


Attempts  have  been  made  to  divide  vesical  tuberculosis  into  primary 
and  secondary  infection,  but  extended  observation  of  individual  cases  and 
records  has  shown  that  it  is  rarely  if  ever  primary  in  the  bladder;  that 
vesical  tuberculosis  is  practically  always  preceded  by  tuberculosis  of  some 
other  organ  or  organs  of  the  body;  also,  that  it  practically  always  implies 
infection  of  some  other  part  of  the  genito-urinary  tract.  In  720  instances 
in  which  the  genito-urinary  organs  were  the  seat  of  tuberculosis,  the  bladder 
was  involved  in  221  cases — 30.7  per  cent. 

That  vesical  tuberculous  infection  is  nearly  always  secondary  is  probably 
because  the  bladder  mucosa  is  lacking  in  absorptive  power  and  therefore  fails 
to  take  up  and  absorb,  until  a  late  date,  the  bacilli  that  may  be  floating  in  the 
contained  urine  or  other  secretions;  and  yet,  even  though  thus  resistant,  it 
Ues  in  the  pathway  of  two  secretions  that  are  notorious  carriers  of  tubercle 
germs,  namely,  the  urine  from  above,  and  the  semen  from  below.  So  that, 
though  retarded  in  its  development,  its  ultimate  impUcation  is  hardly  avoid- 
able if  the  primary  focus  continues  to  pour  bacilli  into  it  over  a  long  enough 
period.  Some  little  crack  or  crevice  in  the  membrane  is  finally  found  to 
act  as  a  point  of  entrance  for  the  organisms.  It  is  true  that  the  semen 
does  not  itself  enter  the  bladder,  but  it  is  also  true  that  ascending  tuber- 
culosis makes  its  way  along  the  pathway  provided  for  the  semen:  the  vas 
deferens,  the  seminal  vesicles,  ejaculatory  ducts,  which  open  into  the  prostatic 
urethra  at  the  vesical  neck.  From  vesicles  or  prostate,  tuberculous  infection 
may  spread  into  the  bladder  by  either  continuity  or  contiguity  of  tissue: 
along  the  mucous  membrane  or  through  the  adjacent  tissues. 

Mode  of  Origin. — Tuberculous  infection  of  the  bladder  is  accomplished 
in  five  different  ways:  (1)  Through  the  blood-vessels;  (2)  through  the 
lymph-channels;  (3)  by  means  of  the  secretions  (the  semen,  urine,  etc.); 
(4)  by  continuity;   (5)  by  contiguity. 

The  early  expression  and  location  of  the  disease  are  much  influenced  by 
the  mode  of  production  of  the  infection.  If  the  implantation  is  an  ascend- 
ing one,  from  testes  and  vesicles  or  prostate,  the  early  manifestation  will  be 
on  the  trigone  or  the  vesical  neck;  but  if  the  germs  have  descended  from  a 
kidney  by  way  of  a  ureter,  the  immediate  neighborhood  of  that  ureteral 
orifice  is  the  point  that  first  capitulates  and  becomes  reddened,  swelled,  in- 

165 


166  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

flamed,  and  finally  ulcerated.  If  the  germs  are  received  from  the  vascular 
systems,  the  walls  of  the  bladder  are  as  likely  as  any  other  parts  to  show  the 
first  involvement;  and  we  then  see  the  early  ulcers  scattered  over  the  mucosa. 

Marital  Tuberculosis. — It  has  been  claimed  that  sexual  intercourse  pre- 
sents a  mode  of  direct  transference  of  tubercle  bacilli  and  infection  frequent 
enough  to  be  taken  into  account.  I  have  myself  observed  instances  of  tliis 
sort,  one  in  particular,  in  which  tuberculosis  of  the  bladder  occurred  in  a  wife 
whose  husband,  a  physician,  was  the  subject  of  advanced  general  tuber- 
culosis, and  the  coincidence  was  very  striking;  but  investigation  into  the 
history  of  the  wife  showed  that  her  own  family  history  was  not  above 
suspicion.  This  question  has  been  the  subject  of  careful  analysis  by  Mr. 
E.  G.  Pope,  of  the  Adirondack  Sanatorium,  who  concludes  that  there  are 
too  many  sources  of  error  to  fix  the  responsibility  of  direct  contagion  on 
matrimonial  association.  He  believes,  further,  that  assortive  mating  (the 
tendency  to  select  those  with  like  marked  tendencies)  accounts  for  two- 
thirds  and  infective  action  for  not  more  than  one-third  of  the  cases.*  If 
this  mode  of  infection  were  frequent,  the  woman  would  be  the  chief  sufferer, 
from  the  deposition  and  retention  of  tubercle  bacilli  in  the  recesses  and  folds 
of  the  vagina;  but  records  indicate  that  women  are  affected  with  vesical 
tuberculosis  about  one-tliird  less  often  than  men. 

Mode  of  Development. — The  stages  of  development  of  tuberculous  cystitis 
may  be  divided  as  follows  (Motz  and  Halle) : 

1.  The  stage  of  invasion  and  formation  of  tubercles. 

2.  The  stage  of  inflammation  and  superficial  ulceration. 

3.  The  stage  of  deeper  infiltration. 

4.  Stage  of  wide-spread  destruction  (Walker). 

In  the  earliest  period  (invasion)  there  are  white  or  gray  tubercles  and 
injected  areas,  without  the  presence,  necessarily,  of  ulceration.  Some  have 
sought  to  call  this  "  tuberculosis  of  the  bladder,"  as  differentiated  from  tuber- 
culous cystitis;  but  the  differentiation  is  artificial — they  are  stages  of  the 
same  process. 

Ulceration  shows  itself  after  the  apex  of  the  tubercle  becomes  necrotic 
and  breaks  down.  These  independent  ulcers  tend  to  coalesce  and  make  the 
larger  ulcers  that  are  typical  of  the  process.  Such  ulcers  are  sharp-edged, 
sometimes  slightly  undermined,  with  their  surface  irregular  and  uneven,  and 
liable  to  be  covered  with  grayish  pseudo membrane,  tinged  with  blood  or  small 
clots  at  times.  The  ulcer  is  surrounded  by  membrane  whose  natural  luster 
is  dimmed,  which  looks  reddened  and  velvety,  and  whose  blood-vessels  are 
lost  in  the  intense  injection  prevailing. 

Clinical  Evidences. — The  clinical  evidences  may  be  described  as  those 
giving  rise  to — (a)  suspicion;  (6)  confirmation;  (c)  conviction.  Suspicion 
*  Quoted  in  Jour.  Am.  Med.  Assn.,  Sept.  5,  1908. 


TUBERCULOSIS  OF  THE  BLADDER. — LEWIS.  167 

of  vesical  tuberculosis  should  be  aroused  by  persistent  and  apparently  in- 
explicable frequency  of  urination,  either  by  night  or  day  or  both;  together 
with  the  appearance,  over  long  periods  of  time,  of  blood-cells,  in  micro- 
scopical quantities,  in  the  urine.  In  the  later  stages,  and  especially  in 
women,  pain  and  harassing  suffering,  day  and  night,  with  interruptions  or 
loss  of  sleep  and  lowering  of  nerve  stamina,  mark  the  more  serious  phases  of 
the  disease.  Persistent  or  recurrent  bleeding  is  apt  to  take  place  from  the 
ulcerated  surfaces,  adding  to  the  depression,  both  mental  and  physical.  More 
important  is  the  persistent  appearance  in  the  urine  of  red  cells  in  micro- 
scopical quantities  in  the  early  periods  of  the  infection.  It  is  important 
because  it  is  early,  furnishing  the  medical  attendant  the  gi'ounds  for  sus- 
picion that,  if  recognized  and  followed  up,  enables  him  to  recognize  the 
disease  at  the  earliest  possible  moment.  But  I  have  found  in  numerous 
instances  that  this  feature  was  not  recognized  or  even  suspected  because 
examinations  of  the  urine  were  not  sufficiently  careful  or  searching.  Such 
urines  are  often  limpid,  clear,  and,  from  the  macroscopical  standpoint,  as  far 
above  suspicion  as  Caesar's  wife,  yet  contain  large  numbers  of  red  cells  in 
every  specimen  voided.  Frank  hematuria  becomes  one  of  the  outspoken 
danger-signals  later,  when  inflammation  or  ulceration  is  established. 

Pain  is  either  spontaneous  or  excited  by  the  act  of  urination.  In  the 
latter  case  it  is  most  intense  at  the  end  of  the  act,  aroused  by  the  squeezing 
of  the  inflamed  and  ulcerated  areas  by  the  vesical  sphincters.  Pain  of  this 
character  is  almost  constant,  at  one  period  or  another,  in  the  tuberculous 
bladder,  and  often  becomes  so  severe  as  to  precipitate  the  patient  into 
morphin  or  cocain  addiction.  But  another  symptom  is  even  more  character- 
istic of  the  disease — that  is,  excessive  tenderness  and  hypersensitiveness 
to  manipulation.  Appreciation  of  this  fact  should  lead  to  the  free  use 
of  local  anesthesia  for  making  any  necessary  local  investigation. 

In  health  the  desire  to  urinate  is  aroused  by  irritation  of  the  mucous 
membrane  of  the  prostatic  urethra  or  neck  of  the  bladder.  Any  irritation 
applied  at  this  point  will  arouse  desire  to  urinate.  When  that  irritant  is 
urine  from  the  full  or  overfilled  bladder,  the  result  is  physiological  desire  to 
urinate  that  passes  off  when  the  bladder  is  evacuated;  when  the  irritant  is 
tuberculous  inflammation  or  ulceration,  there  is  good  reason  for  the  per- 
sistent and  intense  desire  to  urinate,  even  in  the  presence  of  a  comparatively 
empty  bladder.  This  desire  is  uitensified  by  reason  of  the  frequency  with 
which  the  neck  of  the  bladder  is  the  part  especially  involved.  Sometimes 
the  frequency  is  due  to  reflected  irritation  rather  than  direct  inflammation 
there,  as,  for  instance,  from  renal  tuberculosis,  which  occasionally  causes 
frequency  before  the  involvement  of  the  bladder.  . 

Among  the  characteristic  signs  of  vesical  tuberculosis  is  a  marked 
diminution  in  the  capacity  of  the  bladder  (contracted  bladder).     From  three 


168  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

to  four  ounces  is  a  fair  average  capacity  for  such  bladders,  due  to  infiltration 
and  thickening  and  lessened  elasticity  of  the  walls. 

A  peculiarity  noticeable  is  that,  in  the  face  of  this  condition  and  the  pro- 
longed inflammation  prevailing  with  it,  the  urine  is  liable  to  be  acid  in  re- 
action. The  introduction  of  the  proteus  group  of  bacteria  sets  up  ammo- 
niacal  fermentation  that  alters  this,  however,  establishing  alkalinity  and 
adding  to  the  subjective  complaints  and  activity  of  inflammatory  processes. 

Mixed  Infections. — In  addition  to  the  tubercle  bacilli  found  in  tuber- 
culous cystitis,  other  organisms  are  sometimes  present  and  take  an  active 
part  in  the  pathological  processes.  Some  of  them  have  something  to  do 
with  the  inauguration  of  the  tuberculous  infection,  while  others  are  followers 
of  the  tuberculous  infection,  adding  their  quota  to  the  miserable  conditions 
prevailing.  Many  cases  of  urinary  tuberculosis  have  been  observed  as  fol- 
lowers of  urethral  gonorrhea;  while  streptococci,  staphylococci,  colon  bacilli, 
and  other  organisms  have  been  found  as  companions  of  tubercle  bacilli. 
It  is  considered  probable  that  pyogenic  organisms  lower  the  resistance  of  the 
mucosa  and  produce  minute  breaks  in  its  surface,  allowing  the  tubercle  bacilli 
to  enter  the  submucosa.  On  the  other  hand,  it  is  thought  that  cystitis  caused 
by  members  of  the  proteus  group  does  not  offer  so  fertile  a  field  for  the  invasion 
of  tubercle  bacilli  as  that  produced  by  streptococci  and  gonococci  (Walker). 

Diagnosis. — While  the  characteristic  symptoms  and  signs  given  may  be 
sufficient  to  give  rise  to  a  presumptive  diagnosis,  the  crucial  factor,  as  with 
tuberculosis  of  other  parts  of  the  body,  is  the  demonstration  of  the  tubercle 
bacillus  in  connection  with  inflammation  of  the  bladder.  The  appearance  of 
tubercle  bacilli  in  the  urine  does  not  by  any  means  necessarily  indicate  vesical 
tuberculosis,  as  it  has  repeatedly  been  proved  (Israel,  Jani  and  Nakarai,  Thilic- 
wicz)  that  tubercle  bacilli  may  float  in  the  urine  of  persons  whose  urinary 
tract  is  innocent  of  any  pathological  lesion,  even  as  demonstrated  post  mortem. 

The  finding  or  identification  of  the  tubercle  bacilli  in  the  urine  is  not 
always  easy  or  possible,  and  is  largely  dependent  on  accompanying  conditions, 
the  age  and  extent  of  the  lesions,  the  mode  of  search  carried  out,  etc.  The 
bacilli  may  be  sparse  in  number,  and  on  that  account  escape  detection  by 
the  orcUnary  methods.  Bryson  called  attention  to  a  useful  procedure  in 
this  connection,  namely,  the  draining  off,  by  sterile  catheter,  of  the  small 
amount  of  urine  left  over  after  voluntary  urination,  as  offering  a  better 
probability  of  gathering  the  bacilli  that  have  settled  at  the  bottom  of  the 
bladder.  Precaution  should  always  be  taken  against  admitting  smegma 
bacilli  into  the  specimen — this  by  thorough  cleansing  of  the  glans,  meatus, 
and  urethra,  over  which  the  catheter  must  pass.  Sedimentation  should  be 
prompt  and  thorough,  but  not  too  vigorous. 

Failure  to  find  the  bacilli  does  not  prove  their  absence,  and  merely  stands  as 
negative  evidence;  it  must  be  supplemented  with  the  more  accurate  mode 


TUBERCULOSIS  OF  THE  BLADDER. — LEWIS.  169 

of  guinea-pig  inoculation  of  the  urinary  sediment.  This  is  reliable  and  ex- 
tremely valuable — much  more  so,  in  the  writer's  opinion,  than  the  hypoderma- 
tic tuberculin  test.    But  it  requires  from  two  to  three  weeks'  time  for  maturing. 

The  other  necessarj'-  factor  for  fixing  the  diagnosis  of  tuberculous  cys- 
titis is  the  picture  presented  by  the  cystoscope.  "Seeing  is  believing," 
we  are  told;  but  it  must  be  remembered  that  it  requires  an  eye  of  some 
experience  to  see  things  accurately  through  the  cystoscope. 

The  writer  desires  to  express  himself  as  decidedly  opposed  to  the  rather 
broadly  disseminated  view  that  urinary  tuberculosis  means  interdiction  of 
the  use  of  instruments,  either  for  diagnosis  or  for  treatment.  While  due 
conservatism  should  be  exercised  in  this  regard,  the  idea  that  it  is  a  forbidden 
field  should  be  abandoned.  That  idea  is  no  more  applicable  here  than  in 
other  conditions  requiring  the  ministrations  of  surgery  and  medicine.  The 
writer  has  been  gratified  to  obser\^e  participation  in  this  view  by  others, 
notably  Willy  Meyer.*  It  has  been  observed  in  a  number  of  cases  of  severe 
urinar)'  tuberculosis  that  the  repeated  use  of  the  cystoscope,  together  with 
ureter  catheterization  and  other  forms  of  instrumentation,  have  not  retarded 
or  interfered  with  progressive  improvement  or  even  recovery. 

Cystoscopy. — While  characteristic  lesions,  such  as  have  previously  been 
mentioned,  are  shown  by  the  cystoscope  in  tuberculous  inflammation  and 
more  especially  ulceration  of  the  bladder,  it  cannot  be  said  that  the  lesions 
are  always  tj^pical,  or  that  they  adhere  to  hard  and  fast  lines  of  development. 
On  this  subject  Casper f  says:  "In  general,  tuberculosis  of  the  bladder 
does  not  present  a  specific  picture:  besides  diffuse  swelling  and  redness, 
there  are  at  times  deeply  congested  localized  areas  clearly  separated  from 
apparently  healthy  tissue,  while  again  ulcerations  having  nothing  distinctive 
about  them  are  seen.  Tubercles  are  very  seldom  found."  Fcnmckf  says: 
"The  primary  (early)  deposit  is  detected  on  the  posterior  wall  in  two  forms, 
either  diffuse,  as  a  dull  red  patch  or  patches,  or  locahzed,  as  a  single  ulcer 
to  the  inner  side  of  the  ureteric  orifice.  The  dull  red  patches  betoken  ex- 
travasation and  exudation.  I  have  sometimes  met  with  cases  in  wliich  a 
solitary  ulcer  was  seen  to  the  inner  side  of  the  orifice,  and  I  could  not  dis- 
tinguish its  appearance  from  the  solitary  simple  ulcer."  Kneise§  gives  a 
beautiful  colored  picture  of  what  appears  to  be  typical  grayish-yellow 
tubercles,  in  the  neighborhood  of  the  ureteric  orifice,  and  wliich  he  says  were 
at  first  diagnosed  as  tubercles  by  himself  and  so  eminent  an  authority  as 
Professor  Stoeckel ;  but  further  observation  proved  the  fallacy  of  this  diagnosis 
and  established  that  of  simple  cystitis  granulosa — all  of  which  goes  to  show 
that  the  cystoscopic  picture,  important  as  it  is  for  various  reasons,  is  not 
infallible,  and  conclusions  from  it  must  be  drawn  with  due  consideration 
of  the  chnical  history  and  other  features  of  the  case. 

*"New  York  Medical  Journal,"  April,  1907.       f  Bonney's  translation,  p.  224. 
t  "Clinical  Cystoscopy,"  p.  172.    §  "HandatlasderCystoskopie,"  1908,  p.  46, plate  22. 


170  SIXTH    INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

Besides  the  oval  or  rounded  ulcers  with  sharp  edges,  perhaps  undermined, 
with  roughened,  raw,  and  bleeding  surface,  surrounded  by  a  zone  of  conges- 
tion, of  velvety  appearance,  lacking  the  natural  luster;  with  other  areas  of 
congestion  either  localized  or  diffuse — besides  these  characteristic  appear- 
ances of  the  bladder  mucosa  itself,  the  ureteral  orifices  themselves  habitually 
present  characteristic  features  in  connection  with  descending  tuberculosis. 
These  have  been  especially  well  studied  by  Fenwick,  who  says:*  "One  of 
the  ureteric  orifices  is  attacked  before  the  other;  both  are  never  attacked 
equally.  The  orifice  of  that  ureter  on  which  the  stress  of  the  disease  first 
falls  changes  in  contour,  its  lips  thicken,  and  it  becomes  caked  and  patulous. 
The  same  changes  will  be  found  in  the  corresponding  renal  pelvis,  with 
impUcation  of  the  lower  part  of  the  Iddney."  The  same  author  says  that 
where  the  vesical  implication  is  a  descending  one  from  a  tuberculous  kidney 
that  retracts  under  the  ribs,  the  ureter  becomes  stretched  (tense),  the  vesical 
orifice  of  the  ureter  becomes  displaced,  elevating  the  trigonal  angle  of  that 
side  and  perhaps  joresenting  a  funneled  appearance  there — furnishing  a  diag- 
nostic sign  of  material  value.  Instead  of  being  an  inch  and  a  half  from  its 
fellow  and  the  same  distance  from  the  urethral  outlet,  it  is  found  to  be  as  much 
as  two  inches  from  either  opening,  and  is  drawn  both  outward  and  upward. 

The  "therapeutic  test"  is  a  means  which,  sometimes  applied  either 
inadvertently  or  intentionally,  gives  a  fairly  good  indication  of  the  tuber- 
culous or  non-tuberculous  nature  of  a  vesical  inflammation.  Nitrate  of 
silver  solution,  nearly  always  gratefully  received  by  the  infected  bladder, 
arouses  prompt  additional  irritation  if  the  cystitis  is  of  tuberculous  origin. 

The  final  definite  diagnosis  must  occasionally  be  made  without  the 
demonstration  of  the  tubercle  bacillus  and  in  spite  of  indefinite  cystoscopic 
findings,  the  other  indications  present  being  taken  as  sufficient  to  justify 
a  conclusion.  One  sometimes  feels  that  he  is  in  the  presence  of  tuber- 
culosis, without  being  able  to  elicit  the  distinctive,  individual  evidences 
desired.  Then,  too,  the  condition  of  other  organs  of  the  body,  whether 
tuberculous  or  not,  may  have  a  serviceable  bearing  on  the  question. 

Treatment. — The  treatment  of  tuberculous  cystitis  may  be  divided  into 
palliative  or  curative,  by  means  of  hygienic,  systemic,  local,  and  operative 
measures.  Realizing  that  the  affection  is  a  secondary  one,  with  the  original 
focus  situated  at  some  other  part  of  the  body, — in  most  cases  the  kidney 
— this  must  be  considered  in  adopting  a  plan  of  procedure.  With,  for  in- 
stance, a  suppurating  tuberculous  kidney  continually  draining  into  such  a 
bladder,  hope  of  definite  cure  could  only  be  based  on  preliminary  removal 
of  the  kidney;  whereas,  if  the  contributing  focus  were  in  the  lungs,  in- 
volved to  a  serious  degree,  palliation  and  amelioration  of  the  vesical  symp- 
toms would  necessarily  be  the  more  restricted  aim. 

*  Ibid.,  p.  174. 


TUBERCULOSIS  OF  THE  BLADDER. — LEWIS.  171 

Comporting  with  the  more  hopeful  prognosis  given  to  subjects  of  tuber- 
culosis of  other  organs  of  the  body,  in  tliis  latter  day,  it  may  be  conscien- 
tiously declared  that  a  more  cheering  view  of  this  condition  should  be  enter- 
tained. ]\Iodern  means  and  methods  of  coping  with  this  form  of  the  "  wliite 
plague"  amply  justify  tliis  assertion. 

The  various  systemic  and  hygienic  influences  suitable  for  tuberculosis  in 
general  are  indicated,  and  it  would  be  supererogation  to  rehearse  them  here. 
One  fact  is  of  striking  import,  however,  and  should  be  here  considered:  So 
much  good  can  often  be  accomplished  by  local  or  operative  measures  that 
it  is  doubtful  if  these  could  be  given  up  merely  for  the  purpose  of  going 
away  for  "good  air"  and  hygienic  influences. 

Any  local  measure  adopted  should  be  as  httle  irritating  as  possible;  but 
this  does  not  indicate  the  exclusion  of  the  catheter  or  cystoscope  when  they 
are  needed.  Obstructive  conditions  of  the  urethra  should  be  remecUed, 
securing  free  and  easy  transit  for  the  urine,  for  which  dilating  is  preferable 
to  cutting.  Iodoform  oil  emulsion,  with  liquid  vaselin  or  oleolene  as  a 
vehicle,  is  not  only  soothing,  but  markedly  beneficial.  It  is  injected  once 
dail}^,  either  with  or  without  the  aid  of  a  soft  catheter,  and  is  allowed  to 
remain  in  the  bladder  as  long  as  possible,  the  patient  omitting  to  pass  the 
last  drops  in  urinating  subsequently. 

The  formaldehyd  group  of  medicaments  (urotropin,  cystogen)  is  contra- 
indicated;  they  afford  no  service  and  are  often  highly  irritating.  Creasote  and 
guaiacol  in  full  dosage  are  usually  beneficial.  Tuberculin  treatment  occupies 
the  same  position  here  that  it  does  with  reference  to  tuberculosis  at  other 
points  of  the  body,  and  it  should  be  prescribed  under  the  same  regulations. 

In  his  former  frequent  use  of  air-inflation  of  the  bladder  in  connection 
with  air-cystoscopy,  the  writer  observed  so  many  instances  of  definite  and 
sustained  improvement  that  the  question  arose  in  his  mind  as  to  whether 
the  air  itself  were  not  a  beneficent  factor. 

Surgery  has  a  fairly  well-defined  position  in  tuberculous  cystitis,  but  it 
relates  chiefly  to  the  surgery  of  the  contributing  factors,  the  kidneys,  ureters, 
testes,  vesiculse  seminales,  ovaries,  and  tubes.  Experience  has  justified 
removing  the  original  focus,  suppurating  kidney,  or  kidney  and  ureter;  or, 
occasionally,  the  worse  of  two  tuberculous  kidneys,  relieving  the  sufferer 
of  a  suppurating  and  infected  organ  that  is  doing  no  good,  but  is  under- 
mining the  health  and  inciting  infection  elsewhere.  It  is  well  established 
that  bladders  are  reclaimed  from  their  unhealthy  condition  by  removal 
of  the  kidney  that  has  infected  them,  that  they  then  undergo  definite  re- 
parative changes,  the  ulcers  heal,  and  the  inflammation  ceases. 

Under  such  circumstances  certain  authors  have  laid  much  stress  on  total 
removal  of  the  involved  ureter  as  well,  in  the  belief  that  if  any  of  it  is  left 
behind,  it  will  prove  a  source  of  renewed  infection  later.    This  latter  claim 


172  SIXTH   INTERNATIONAL   CONGEESS   ON   TUBERCULOSIS. 

has,  however,  not  been  established.  As  above  mentioned,  the  tuberculous 
bladder  is  able  to  clear  up  and  regain  its  health  after  removal  of  the  the  sup- 
purating kidney;  why  not  the  ureter  as  well?  While  it  is  theoretically 
better  to  be  rid  of  a  tuberculous  ureter,  its  removal  in  serious  cases  cannot 
fail  to  add  to  the  duration  and  seriousness  of  the  operation,  possibly  to 
the  extent  of  compromising  the  chances  of  the  patient.  In  view  of  the 
doubtful  advantage  gained,  is  it  worth  while  to  run  the  risk?  This  question 
refers  more  particularly  to  cases  of  low  \'itality,  I  confess  my  own.  leaning 
to  the  negative  side  of  the  question.  Two  years  ago,  acting  on  this  reason- 
ing, I  removed  the  left  kidney  of  a  young  woman  who  was  so  depleted  in 
health  and  strength  that  the  medical  attendants  were  united  in  the  belief 
that  she  could  not  withstand  the  effects  of  removal  of  the  affected  ureter 
also.  It  was  left  behind;  the  patient,  though  in  a  precarious  condition 
for  several  days,  recovered;  her  bladder  has  since  cleared  up  from  both 
inflammation  and  ulceration;  the  ureter  of  that  side  has  become  obliterated, 
discharges  nothing,  and  is  not  even  patent  to  a  catheter.  The  patient  has 
gained  about  thirty  pounds  and  her  general  health  is  practically  restored. 

The  use  of  bichlorid  of  mercury  solution,  either  in  the  form  of  instilla- 
tions or  by  swabbing  after  curetting,  with  or  without  suprapubic  access,  has 
received  high  encomiums  from  Guy  on  and  numerous  followers,  and  should  be 
tried  after  less  heroic  measures  have  failed.  Permanent  vesical  fistula  may 
become  a  necessity  of  the  later  stages  of  tuberculous  ulceration,  draining  the 
bladder  through  a  suprapubic  opening  in  the  male,  or  the  vagina  in  the  fe- 
male.    But,  like  the  mention  of  it  in  this  paper,  it  should  be  a  measure  of  last 

resort 

DISCUSSION. 

Dr.  Guy  L.  Hunner  (Baltimore). — ^From  the  patient's  standpoint,  few 
diseases  are  of  more  importance  than  tuberculosis  of  the  bladder,  as  few  or 
none  cause  more  suffering  and  but  few  are  more  intractable. 

From  the  viewpoint  of  this  great  Congress,  whose  watchword  is  "preven- 
tion," I  am  certain  that  we  have  not  given  serious  enough  attention  to 
the  extreme  menace  of  urinary  tuberculosis  as  a  disseminator  of  the  plague. 
This  must  be  impressed  upon  those  who  use  the  microscope  and  often  see 
hundreds  or  thousands  of  tubercle  bacilli  in  one  field  of  centrifugalized  urine. 
The  danger  of  spreading  the  disease  from  this  source  is  more  to  be  considered 
in  women,  in  whom  the  act  of  voiding  is  attended  with  contamination  of  the 
genitalia  and  clothing,  whence  the  dried  bacilli  may  later  be  given  off  to 
the  patient's  surroundings. 

Substantial  progress  has  been  made  during  the  past  ten  years,  and  particu- 
larly in  the  past  five  years,  on  the  questions  of  etiology,  diagnosis,  pathology, 
treatment,  and  prognosis. 

Five  years  ago,  in  a  paper  reporting  thirty-five  cases  then  having  occurred 
in  the  practice  of  Howard  A.  Kelly  and  his  associates,  I  expressed  the  opinion 


TUBERCULOSIS  OF  THE  BLADDER. — LEWIS.  173 

that  practically  all  cases  of  bladder  tuberculosis,  in  women  at  least,  are 
secondary  to  tuberculosis  of  the  kidney.  This  view  is  now  generally  accepted, 
and  it  is  important  from  the  standpoint  of  diagnosis  and  treatment. 

In  making  a  diagnosis  of  the  nature  of  a  case  of  cystitis,  it  is  my  practice 
to  consider  every  case  one  of  tuberculosis  until  it  is  proved  otherwise.  Gonor- 
rheal, puerperal,  postoperative,  and  foreign  body  cystitis  usually  present  a 
clear  history'-  and  other  means  of  a  ready  diagnosis.  One  must  not  forget 
that,  even  in  a  tuberculous  case,  the  first-marked  symptoms  may  arise  be- 
cause of  a  gonorrheal  or  other  infection  becoming  engrafted  on  the  more  in- 
sidious disease,  and  setting  up  a  sudden  and  more  acute  condition. 

In  any  case  of  cystitis  we  suspect  tuberculosis  if  the  culture  test  is  nega- 
tive, particularly  if  the  culture  is  taken  on  special  gonorrhea  media  and  if 
gonococci  are  absent  from  the  centrifugalized  specimen. 

A  cystitis  that  refuses  to  react  favorably  to  the  ordinary  methods  of 
treatment  is  suspicious.  The  presence  of  disease  of  one  or  both  kidneys 
makes  us  more  suspicious  of  tuberculosis. 

The  cystoscope  is  our  greatest  aid.  In  the  first  place,  it  demonstrates 
whether  there  is  an  actual  cystitis,  an  important  point  in  view  of  the  fact  that 
many  cases  in  which  the  disease  is  confined  to  the  kidney,  or  to  the  kidney 
and  ureter,  have  bladder  symptoms,  but  no  cystitis.  I  must  confess  that  we 
are  not  always  so  fortunate  as  to  find  a  picture  which,  from  the  cystoscope 
alone,  we  can  confidently  claim  to  be  a  tuberculous  cystitis.  The  finding  of 
tubercle  bacilli  in  the  urine  by  the  microscope  or  by  the  inoculation  test  is 
necessary  for  an  absolutely  positive  diagnosis. 

In  the  treatment  of  bladder  tuberculosis  we  usually  make  but  little  prog- 
ress until  the  disease  in  the  upper  tract  is  eradicated.  I  wish  to  call  particular 
attention  to  one  class  of  cases  in  which  it  is  sometimes  advisable  to  begin 
treatment  at  the  bladder  end  of  the  urinary  tract.  We  see  an  occasional 
case  with  tuberculosis  of  both  Iddneys,  or  tuberculosis  of  one  kidney,  ureter, 
and  base  of  the  bladder,  with  swelling  of  the  lower  end  of  the  other  ureter 
and  a  secondary  pyelitis  of  the  better  kidney.  It  is  advisable  in  some  of  these 
cases  to  begin  treatment  by  making  a  vesicovaginal  fistula  and  placing  the 
bladder  at  physiological  rest.  This  makes  the  patient  more  comfortable,  especi- 
ally if  the  tub-bath  treatment  be  used;  and  by  increased  hours  of  sleep 
and  greater  capacity  for  food,  the  patient  can  be  put  in  better  condition  for 
operation  on  the  worst  kidney,  and  at  the  same  time  the  swelling  of  the  second 
ureter  disappears  and  allows  a  restitution  of  the  secondarily  infected  kidney. 

Two  of  my  cases,  one  a  girl  of  nineteen,  another  a  woman  of  fifty-three, 
looking  hopeless  on  first  sight,  because  of  thickening  of  both  ureters  and  pus 
from  both  sides,  are  perfectly  well  to-day  after  following  tliis  method  of 
treatment.  The  supposedly  better  side  in  each  of  these  cases  could  not  be 
catheterized  because  of  the  thickened,  obstructed  ureter,  but  the  worst  side 
was  catheterized  and  tubercle  bacilli  found.     In  each  case  a  vesicovaginal 


174  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

fistula  was  made,  and  after  decided  improvement  in  general  health  the  worst 
kidney  was  removed,  and  eventually  the  remaining  side,  which  at  first  could 
not  be  catheterized,  lost  its  ureter  thickening  and  the  pyelitis  and  cystitis 
entirely  cleared  up.  In  a  third  similar  case  I  actually  found  tubercle  bacilli 
in  the  urine  catheterized  from  the  better  side.  After  a  few  months  of 
treatment  there  was  no  sign  of  a  pyelitis  on  this  side  and  the  bad  kidney 
was  then  removed. 

In  the  paper  above  referred  to,  written  five  years  ago,  I  expressed  a  doubt 
as  to  whether  any  case  of  tuberculous  cystitis  could  be  cured  without  surgical 
eradication  of  the  disease.  Experience  has  shown  that  a  brighter  prognosis 
may  be  entertained.  We  must  remember  that  the  cystitis  associated  with 
tuberculosis  of  the  kidney  is  often  of  a  non-specific  nature,  and  readily  clears 
up  after  removal  of  the  diseased  kidney.  I  believe  that  some  cases  which 
are  specific  will  clear  up  spontaneously  in  from  one  to  five  years  if  the  patient 
is  given  a  favorable  environment.  I  believe  we  hasten  the  cure  by  placing 
the  bladder  at  rest  with  a  vesicovaginal  fistula,  although  this  may  prove 
a  disagreeable  method  to  the  patient.  My  experience  corresponds  with 
that  of  Guyon  and  Casper  in  the  use  of  the  bichlorid  of  mercury.  Most 
patients  are  greatly  benefited  by  the  biweekly  instillations  of  the  mercury 
bichlorid  in  strengths  of  1:40,000  up  to  1:5000,  and  I  believe  the  cure  is 
hastened  by  this  method.  Whether  there  is  a  specific  action  of  the  mercury 
or  whether  the  improvement  results  from  the  counterirritant  action  I  am 
not  prepared  to  say;  but  from  the  fact  that  silver,  which  is  so  useful  in  most 
forms  of  cystitis,  seems  to  have  a  harmful  rather  than  beneficial  effect  in  the 
tuberculous  form,  it  would  seem  that  the  mercury  has  a  specific  action. 

Dr.  Willy  Meyer  (New  York)  said  there  could  be  no  question  but  that, 
in  probably  more  than  95  per  cent,  of  cases,  tuberculosis  of  the  bladder  was  a 
descending  process,  but  he  was  firmly  convinced  that  primary  tuberculosis 
of  the  prostate,  which  so  often  followed  a  primary  invasion  of  the  gono- 
coccus,  did  exist  and  was  to  be  considered  as  a  cause  of  tuberculosis  of  the 
bladder.  Every  means  at  our  disposal  should  be  exhausted  in  attempting 
to  arrive  at  a  correct  diagnosis — careful  history,  careful  examination  of  the 
twenty-four-hour  urine,  inoculation  of  guinea-pigs,  a;-ray,  cystoscopy,  and 
the  various  tests  of  the  functional  activity  of  the  kidney.  The  a;-ray  should 
be  used  before  cystoscopy,  in  order  to  exclude  stone.  Personally,  he  favored 
the  indigo-carmin  test,  though  none  of  these  tests  is  reliable  alone.  The 
finding  of  ulcers  on  the  same  side  as  the  pain  in  the  kidney  is  a  pretty  sure 
sign  as  to  which  side  the  disease  is  on. 

Dr.  Louis  E.  Schmidt  (Chicago)  reported  two  cases  that  had  consulted 
him  on  account  of  hematuria.  In  each  case  nephrectomy  was  advised.  The 
first  patient,  a  medical  student,  refused  operation  and  went  under  vaccine 
treatment.  That  was  a  year  and  a  half  ago,  and  he  returned  three  or  four 
weeks  ago,  with  a  history  that  two  and  a  half  months  previously  he  had  had  a 


TUBERCULOSIS   OF  THE   BLADDER. — DISCUSSION.  175 

nephrectomy.  Cystoscopy  showed  that  liis  entire  bladder  was  now  tuberculous. 
The  second  patient  consented  and  had  a  nephrectomy  a  year  and  a  half  ago, 
and  when  seen  a  few  weeks  ago,  was  entirely  free  from  symptoms.  These  cases 
were  cited  to  show  the  value  of  early  diagnosis  and  nephrectomy.  In  the 
treatment  of  the  bladder  after  nephrectomy,  and  also  where  the  kidneys  are 
so  badly  diseased  that  nephrectozny  is  not  advisable,  more  attention  should 
be  paid  to  the  hygienic  and  climatic  treatment  than  to  the  local  treatment. 

Dr.  William  E.  Lower  (Cleveland,  Ohio)  said  that  in  his  experience 
tuberculosis  of  the  kidneys  is  much  more  frequent  in  women  than  in  men, 
the  proportion  being  about  three  to  one.  He  has  tried  all  manner  of  treat- 
ment of  the  tuberculous  bladder  following  nephrectomy,  but  has  obtained 
the  best  results  with  the  method  of  Rovsing,  the  injection  of  a  5  per  cent, 
solution  of  carbolic  acid  into  the  bladder  about  once  a  week  and  allowing  it 
to  remain  in  the  bladder  from  twenty  to  thirty  minutes. 

Dr.  Korsell  (Chicago)  reported  a  case  of  tuberculosis  of  the  bladder 
which  was  not  accompanied  by  tuberculosis  of  the  kidney.  After  several 
weeks  in  bed  and  local  treatment  with  iodoform  emulsion,  together  with 
constitutional  treatment,  she  made  a  rapid  recovery.  The  urine  had  been 
examined  every  day  for  a  month  by  a  competent  man  and  no  evidences  of 
kidney  disease  were  found.  The  origin  of  the  infection  was  probably  a  tuber- 
culous peritonitis,  the  bacilli  reaching  the  bladder  through  the  urine. 

Dr.  K.\ro,  in  closing,  said  the  evidence  offered  by  Dr.  Korsell  is  not 
sufficient  to  disprove  kidney  tuberculosis.  In  the  case  of  tuberculosis  of 
the  kidney  the  diseased  portion  of  the  kidney  might  become  walled  off  and 
the  case  recover  without  interference.  In  his  opinion  it  is  absolutely 
useless  to  treat  a  tuberculous  bladder  so  long  as  one  or  both  kidneys  were 
affected.  A  little  experience  would  enable  one  to  differentiate  between  the 
smegma  bacillus  and  the  tubercle  bacillus.  The  smegma  bacillus  was  shorter 
and  thicker  and  differently  grouped  on  the  slide.  Hygienic  measures  are 
not  applicable  in  the  case  of  the  poorer  classes.  Where  one  kidney  is 
tuberculous  and  the  other  healthy,  nephrectomy  is  the  operative  proce- 
dure of  choice.  If  both  kidneys  are  affected,  usually  one  is  more  so  than  the 
other,  and  after  having  found  out  by  the  phloridzin  test  and  by  determining 
the  freezing-point  of  the  blood,  and  by  every  other  means,  which  of  the 
affected  kidneys  is  in  the  worse  condition,  he  would  not  hesitate  to  make 
a  nephrectomy  on  the  more  diseased  side.  He  prefers  to  leave  the  ureter 
to  take  care  of  itself.  He  had  not  had  good  results  from  suturing  the 
ureter  in  the  wound. 

Dr.  Lewis,  in  closing,  said  he  believed  it  would  be  a  source  of  danger 
for  one  to  rely  vnth.  confidence  on  his  ability  to  differentiate  between  the 
smegma  and  the  tubercle  bacillus  in  a  given  specimen.  He  would  rather 
place  his  reliance  on  the  exclusion  of  the  smegma  bacilli  from  the  specimen 
than  on  the  differences  in  size,  shape,  and  grouping. 


TUBERCULOSIS  OF  THE  KIDNEY. 

By  Dr.  Arthur  Dean  Bevan, 

Chicago. 


During  the  last  fifteen  years  much  light  has  been  thrown  upon  the  subject 
of  kidney  tuberculosis.  Up  to  that  time  kidney  tuberculosis  was  regarded 
as  a  rare  lesion,  difficult  to  diagnose,  not  mocUfied  by  treatment,  and  ter- 
minating in  a  fatal  issue.  To-day  it  is  known  that  kidney  tuberculosis 
is  a  fairly  common  disease,  and  means  have  been  found  which  make  it 
possible  to  diagnose  the  condition  early,  and  surgical  treatment  has  been 
shown  to  be  capable  of  saving  the  majority  of  patients. 

In  a  series  of  more  than  5000  postmortems  3  per  cent,  were  found 
to  have  tuberculous  lesions  of  the  kidney,  and  of  a  large  series  of  post- 
mortems of  individuals  dying  of  tuberculosis,  10  per  cent,  were  found  to 
have  tuberculosis  of  the  kidneys. 

Etiology. 

Tuberculosis  of  the  kidney  is  the  result  of  hematogenous  infection.  It  is 
probably  almost  always  deuteropathic,  and  seldom,  if  ever,  protopathic. 
This  is  true  even  in  the  cases  where  the  clinical  evidence  and  after-history 
warrant  the  diagnosis  of  primary  kidney  tuberculosis.  In  other  words, 
primary  kidney  tuberculosis  is  seldom,  if  ever,  protopathic  in  the  sense  that 
it  is  actually  the  first,  the  primary  lesion,  but  it  is  always  deuteropathic 
in  the  sense  that,  although  it  is  clinically  the  only  lesion  or  the  first  lesion 
to  give  clinical  evidence  of  its  existence,  it  is,  in  fact,  secondary  to  some 
unrecognized  j^rimary  lesion  elsewhere,  usually  in  a  lymph-gland. 

Kidney  tuberculosis  is  in  90  per  cent,  or  more  of  the  cases  at  first  uni- 
lateral, and  limited  to  the  tissue  of  a  single  kidney.  The  clinical  evidence 
on  this  point  is  now  very  definite  and  convincing.  There  is  an  apparent, 
but  not  a  real,  difference  between  the  clinical  evidence  and  the  autopsy 
findings  on  this  point.  Post-mortem  examinations  show  a  majority  of  cases 
with  bilateral  involvement,  and,  at  the  same  time,  other  gi'oss  and  important 
tuberculous  lesions. 

The  refined,  modern  means  of  diagnosis,  the  exploratory  operations  and 
the  nephrectomies  undertaken  for  tuberculosis  of  the  kidney,  show  that  90 
per  cent,  or  more  of  the  cases  are  unilateral.    The  conclusion  is  evident  that 

176 


TUBERCULOSIS   OF   THE   KIDNEY. — BEVAN.  177 

tuberculosis  of  the  kidney  is,  as  a  rule,  at  first  unilateral;  that  later  the 
disease  extends  and  involves  other  organs  and  the  other  kidney,  so  that, 
in  the  fatal  cases,  both  kidneys  are  usually  involved.  The  tubercle  bacilli 
are  brought  to  the  kidney  by  the  blood-stream,  and  according  to  the  location 
and  character  of  the  resulting  lesions  three  different  types  are  found:  First, 
the  cavernous  type ;  the  type  where  either  in  the  upper  or  lower  pole  several 
good-sized  foci  develop  between  the  capsule  and  the  cavity  of  the  kidney, 
at  first  not  involving  either  the  fibrous  capsule  or  the  mucous  membrane 
lining  the  calyces  or  pelvis.  These  lesions  break  down  and  form  tuberculous 
cavities  var}dng  in  size  from  a  pea  to  an  English  walnut.  Later  these 
cavities  break  into  the  calyces  and  pelvis  and  invade  these  structures,  or  at 
times  break  through  the  fibrous  capsule  and  produce  perinephritic  processes. 

The  second  t}'pe,  the  disseminate  tuberculosis,  is  one  in  which,  throughout 
the  kidney,  there  appears  a  multitude  of  lesions  of  small  size.  This  type 
resembles  the  acute  hematogenous  pyogenic  infection  of  a  single  kidney. 
The  third  appears  as  an  ulcerating  lesion.  All  three  of  these  forms  may 
appear  in  the  same  case,  and  var3dng  combinations  of  the  three  may  occur. 
Tuberculosis  of  the  kidney  sooner  or  later  extends  to  the  ureter  and  blad- 
der. In  tliis  connection  a  word  on  the  general  subject  of  the  so-called 
genito-urinary  tuberculosis  might  be  of  service. 

We  now  know  that  there  should  be  a  distinct  fine  drawn  between  genital 
and  urinary  tuberculosis.  Urinary  tuberculosis  begins  always  in  the  kidney, 
and  then  later  descends  into  the  ureter  and  invades  the  bladder.  In  the 
male,  genital  tuberculosis  begins  usually  in  the  epididymis,  occasionally 
in  the  prostate,  follows  the  flow  of  the  excretions,  and  later  invades  the  vas 
deferens  and  seminal  vesicles,  prostate,  and  bladder. 

In  the  female,  genital  tuberculosis  begins  in  the  tubes  and  invades  peri- 
toneum, uterus,  and  ovary,  but  does  not  extend  to  the  bladder.  Both  ex- 
perimental and  clinical  evidence  seems  to  show  conclusively  that  the  ex- 
tension of  the  tuberculous  process  in  urinary  and  genital  tuberculosis  is  with 
the  stream  of  excretion;  that  is,  from  the  kidney  to  the  bladder,  and  from 
the  epididymis  to  the  prostate  and  bladder.  It  is  probable  that  the  reverse 
does  not  occur,  i.  e.,  ascending  infections  from  epididymis  to  bladder  and 
then  from  bladder  to  kidney,  as  was  formerly  generally  believed.  Where 
these  extensive  pictures  occur,  they  are  to  be  interpreted  as  evidences  of 
several   coincidental   infections  or  cases  of  wide-spread  general  infection. 

In  the  few  early  cases,  where  both  the  urinary  and  genital  organs  are 
involved,  as,  for  instance,  a  single  kidney  and  one  epididymis,  these  are  to 
be  regarded  as  two  independent  foci,  just  as  the  occurrence  of  bone  and  joint 
tuberculosis  in  one  ankle  and  in  one  hip.  In  fact,  there  is  a  very  close  parallel 
between  tuberculosis  of  bones  and  joints  and  tuberculosis  of  the  urinary  and 
genital  organs.     Both  are  hematogenous  infections,  both  deuteropathic  and 


178  SIXTH    INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

secondary  usually  to  an  obscure  lymphatic  lesion.  We  are  now  well  ac- 
quainted with  hip  tuberculosis  as  a  unilateral  lesion,  and  regard  bilateral 
hip  disease  as  a  rarity.  Why  should  we  doubt  when  we  are  told  that  kidney 
tuberculosis   is    also  a  unilateral    disease?     Why  should   it   be  bi-lateral? 

Statistics  vary  as  to  the  relative  frequency  of  the  disease  in  men  and 
women.  The  evidence  would  seem  to  point  to  the  fact  that  clinically  it  is 
recognized  more  frequently  in  women  than  in  men,  but  that  at  postmortem 
it  is  found  more  frequently  in  the  male.  Statistics  vary  also  as  to  the 
frequency  of  involvement  of  the  two  kidneys,  right  and  left.  Some  evidence 
seems  to  point  to  a  gi-eater  frequency  on  the  right  side,  this  being  in  keep- 
ing with  infections  of  the  kidneys  in  general,  and  the  explanation  that  the 
right  kidney  is  more  often  movable  and  possibly  more  subject  to  injury 
and  interference  with  its  blood-supply  because  of  this  greater  movability 
is  submitted.  The  difference  is  probably  not  sufficient  to  be  important, 
however.  Kiister  found,  in  352  cases  of  unilateral  kidney  tuberculosis, 
189  in  the  right  and  163  in  the  left  kidney. 

Gonorrhea  and  other  pyogenic  infections  of  the  urinary  organs  are  im- 
portant etiological  factors;  this  fact  seems  clearly  established ;  the  probable 
explanation  is  that  these  acute  infections  injure  the  structures,  lower  the 
vitality,  and  favor  the  localization  of  the  tubercle  bacilli. 

I  have  in  several  cases  found  the  combination  of  stone  and  tuberculosis 
in  the  kidney.  There  are  two  types  of  this  picture — one  with  primary  stone 
and  tuberculosis  (here  it  is  probable  that  the  stone  favors  the  localization 
of  the  tuberculous  process) ;  the  other  picture  is  that  of  secondary  stone  and 
tuberculosis  (here  it  is  probable  that  the  tuberculosis  precedes,  and  that  the 
secondary  stone  is  the  result  of,  a  mixed  infection  present). 

What  is  the  natural  history  of  kidney  tuberculosis  uninterfered  with 
by  treatment?  A  tuberculous  process  developing  in  a  kidney  might  go  on  to 
spontaneous  cure,  as  occurs  in  other  organs  and  tissues  of  the  body.  The 
foci  become  encapsulated  by  a  firm  wall  of  connective  tissue,  the  focus 
eventually  being  replaced  by  scar  tissue  or  undergoing  calcification.  Al- 
though this  is  possible,  it  would  seem  an  extremely  rare  termination.  The 
autopsy  and  clinical  evidence  seem  to  point  to  the  fact  that  the  process 
extends  and  involves  eventually  the  entire  kidney.  This  may  occur,  and 
the  lesion  run  a  silent  course,  with  complete  destruction  of  the  kidney  tis- 
sue, and  a  spontaneous  cure  result.  The  kidney  becomes  changed  to  a 
mass  of  caseous  material  surrounded  by  a  dense  fibrous  capsule,  or  the  place 
of  the  kidney  tissue  may  be  largely  taken  by  a  mass  of  chronically  inflamed 
fatty  tissue.  In  such  a  case  the  patient  is  in  much  the  same  position  as  a 
patient  who  has  a  tuberculous  kidney  removed  by  operation,  the  diseased 
kidney  being  completely  destroyed  and  so  encapsulated  as  to  be  rendered 
comparatively  innocuous. 


TUBERCULOSIS    OF   THE    KIDNEY. — BEVAN.  179 

Such  spontaneous  cures  are  rare,  and  form  a  small  per  cent,  of  the  total 
cases.  The  usual  course  is  the  extension  of  the  process  to  the  pelvis,  ureter, 
and  bladder,  or  to  the  perinephritic  tissues.  The  gradual  weakening  of  the 
patient,  with  sooner  or  later  wide-spread  tuberculosis,  with,  in  the  majority 
of  the  cases,  involvement  of  both  kidneys  and  death. 

Symptoms. 

Kidney  tuberculosis  is  symptomless  until  the  process  has  extended  to  the 
calyces  or  pelvis  or  to  the  perinephritic  tissues.  The  earliest  and  most 
important  symptoms  are  frequency  of  urination  and  turbid  urine;  a  cysti- 
tis, which  is  not  clearly  gonorrheal  or  due  to  instrumentation,  should  sug- 
gest the  possibility  of  tuberculosis  of  the  kidney  and  urinary  tract,  and 
lead  to  the  exhaustive  examination  of  the  urine  for  tubercle  bacilli. 

Pain  and  tenderness  in  the  kidney  region  may  occur  or  may  be  absent. 
These  symptoms  vary  from  a  mere  sense  of  pain  or  discomfort  in  the  kidney 
or  above  Poupart's  ligament  to  the  outspoken  picture  of  kidney  colic,  simu- 
lating kidney  colic  from  stone,  and  due  to  the  plugging  of  the  ureter  with  blood 
or  tuberculosis  debris.  Hematuria  occurs  in  about  25  per  cent,  of  the  cases, 
and  may  be  severe,  even  fatal,  or,  on  the  other  extreme,  may  be  barely  macro- 
scopical  or  even  microscopical  in  amount. 

Pyuria  is  one  of  the  most  constant  symptoms  of  kidney  tuberculosis; 
mixed  infection,  usually  due  to  colon  bacilli,  is  common.  The  urine  is  usually 
acid  in  kidney  tuberculosis,  but  may,  in  mixed  infections,  be  alkaline.  In- 
crease in  size  of  the  kidney  occurs  in  many  cases,  especially  when  there  is 
present  a  perinephritic  process.  There  may,  however,  be  an  actual  decrease 
in  the  size  of  the  organ. 

Early  diagnosis  is  of  extreme  importance  in  kidney  tuberculosis.  To-day 
the  broad  diagnosis  of  genito-urinary  tuberculosis  will  not  suffice.  The  diag- 
nosis must  determine  the  original  focus,  whether  one  or  both  kidneys  are 
involved,  whether  the  bladder  is  involved  and  to  what  extent,  and  whether 
there  is  involvement  of  other  organs,  as  the  lungs,  etc.,  in  the  tuberculous 
process. 

The  differential  diagnosis  must  be  made  between  cystitis  due  to  other 
causes,  and  pyelitis  due  to  other  infections,  and  such  kidney  lesions  as  kidney 
stone,  neoplasms,  polycystic  degeneration  of  the  kidneys,  essential  hematuria, 
and  acute  and  chronic  pyelonephritis,  pyonephrosis,  and  hydronephrosis  of 
other  etiology.  In  the  majority  of  cases  the  patient  presents  the  symptoms 
and  is  treated  for  a  chronic  catarrh  of  the  bladder. 

Here  the  diagnosis  must  be  made  by  the  finding  of  tubercle  bacilli  in  the 
urine.  The  finding  of  tubercle  bacilli  in  the  urine  is  largely  a  matter  of  care, 
patience,  and  proper  technic.  They  can  almost  always  be  found  in  a  tuber- 
culous process  of  the  kidney  which  is  giving  sufficient  symptoms  to  drive 
the  patient  to  consult  a  physician. 


180  SIXTH    INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

A  twenty-four-hour  specimen  of  urine  should  be  allowed  to  settle,  the 
sediment  should  be  obtained  and  centrifuged,  and  properly  stained  and  ex- 
amined. In  order  to  exclude  smegma  bacilli,  the  specimen  should  be  obtained 
with  catheter  and  destained  with  acid  alcohol.  A  single  negative  examina- 
tion should  not  be  accepted.  If  necessary,  half  a  dozen  specimens  should  be 
examined.  If  tubercle  bacilli  are  found,  a  cystoscopic  examination  of 
the  bladder  should  be  made,  and  the  question  of  bladder  and  ureter  in- 
volvement determined.  The  process,  when  it  has  involved  the  ureter, 
gives  often  a  characteristic  picture  in  the  cystoscopic  examination,  redness 
and  swelling  of  the  mouth  of  the  ureter  on  the  affected  side,  with  ecchy- 
moses,  tubercles,  and  ulceration. 

After  definitely  determining  the  existence  of  a  tuberculous  lesion  of  the 
kidney  in  this  way,  it  becomes  necessary  to  determine  the  existence  and  the 
condition  of  a  second  kidney;  this  can  best  be  done  by  catheterizing  the 
ureters,  and  collecting  and  examining  separately  the  right  and  left  urines. 
In  addition  to  this,  where  surgical  treatment  is  considered,  a  cryoscopic  ex- 
amination of  the  blood  is  made  to  determine  the  question  of  kidney  suffi- 
ciency. If  it  is  normal,  55-57  or  even  up  to  59,  a  nephrectomy  may  be 
safely  undertaken. 

Calculous  pyelitis  often  gives  the  same  general  clinical  picture  as  tuber- 
culosis of  the  kidney.  The  differentiation  can  be  made  by  an  x-ray  ex- 
amination. The  negative  evidence  of  a;-ray  plates  of  the  kidney  region, 
which  possess  proper  definition,  can  be  relied  upon,  and  in  this  way  calculous 
disease  may  be  excluded. 

Neoplasms  of  the  kidney,  especially  the  common  form  of  neoplasm  in  the 
adult, — i.  e.,  hypernephroma, — gives  the  symptom-complex  of  pain  and  ten- 
derness, hematuria,  and  palpable  enlargement,  but  lacks  the  turbid  urine, 
frequency  of  urination,  and  cystoscopic  picture  of  tuberculosis.  Pyelitis 
and  pyonephrosis  from  pus  infections  must  be  differentiated  by  the  examin- 
ation of  the  urine  for  tubercle  bacilli.  In  polycystic  disease  with  hematuria 
both  kidneys  are  usually  palpably  enlarged,  and  no  tubercle  bacilli  are 
found. 

In  the  now  small  proportion  of  cases  in  which  tubercle  bacilli  are  not 
found  in  the  urine,  but  where  the  clinical  picture  strongly  suggests  tubercu- 
losis, animal  inoculation  may  be  employed  or  the  tuberculin  test  resorted  to. 

Treatment. 
Our  present  knowledge  of  kidney  tuberculosis  is  so  recent  that  one  reads 
the  average  text-book  of  medicine  in  vain  for  a  satisfactory  description  of 
kidney  tuberculosis.  The  subject  is  usually  discussed  in  a  short  paragraph 
in  the  general  chapter  on  Tuberculosis,  and  is  not  mentioned  at  all  in  the 
chapters  on  Diseases  of  the  Kidney.    This  fact  may  in  part  explain  the  lack 


TUBERCULOSIS   OF   THE   KIDNEY. — BEVAN.  181 

of  information  of  the  general  practitioner  on  this  subject.  He  has  not 
had  the  subject  properly  presented  to  him.  This  fault  should  be  corrected. 
Means  must  be  found  to  instruct  the  family  physicians  that  tuberculosis 
of  the  kidney  is  a  common  disease,  that  by  proper  methods  the  diagnosis 
can  be  made  early,  and,  what  is  of  the  greatest  importance,  that  the  majority 
of  the  cases  early  diagnosed  can  be  cured. 

It  is  very  important  to  have  this  done  because  the  family  physician  sees 
and  treats  these  cases  in  their  early  stage,  and  frequently  throughout  their 
course,  and,  as  a  rule,  without  recognizing  the  condition. 

Three  methods  of  treatment  have  been  advocated: 

1.  The  general  hygienic  treatment,  which  is  employed  in  lung  tuberculosis. 

2.  The  specific  treatment  with  tuberculin. 

3.  The  surgical  treatment. 

Before  discussing  the  treatment,  let  us  again  remind  you  of  the  fact 
that  spontaneous  cure  of  kidney  tuberculosis  is  probably  rare  and  that  the 
cases  in  which  a  cure  has  apparently  occurred  are,  as  a  rule,  cases  of  unilateral 
kidney  tuberculosis  with  complete  destruction  of  the  kidney  and  occlusion 
of  the  ureter,  with  resulting  cessation  of  symptoms. 

1.  General  hygienic  treatment  is  of  great  importance,  as  in  all  cases  of 
tuberculosis.  Fresh  air,  proper  nutrition,  and  rest  are  of  much  value  and 
should  always  be  insisted  upon.  Cures  occur  under  such  treatment,  but, 
as  already  stated,  they  are  rare.  In  the  light  of  our  present  knowledge  we 
are  not  warranted  in  depending  upon  hygienic  treatment  alone. 

2.  The  specific  treatment  with  tuberculin  is  at  present  on  trial,  especially 
as  advocated  by  Wright,  in  very  small  doses  and  controlled  by  determining 
the  opsonic  index.  Wright  and  some  of  his  followers  are  enthusiastic  in 
their  claims  for  this  treatment,  especially  in  urinary  tuberculosis.  I  know 
of  several  cases  which  have  recovered  under  this  treatment. 

It  goes  without  saying  that  the  entire  medical  world  will  welcome  with 
open  arms  and  adopt  with  enthusiasm  this  treatment  as  soon  as  its  value 
is  demonstrated.  Has  its  value  been  demonstrated?  I  am  afraid  not. 
In  surgical  tuberculosis  in  general,  as  gland,  bone  and  joint,  and  skin  tuber- 
culosis, has  it  supplanted  other  methods  of  treatment?  Unfortunately,  no. 
A  few  cases  of  urinary  tuberculosis  have  apparently  recovered  under  this 
treatment,  but  side  by  side  Avith  these  can  be  placed  a  much  larger  number 
of  cases  which  have  apparently  recovered  without  any  or  with  simple  hygienic 
treatment.  Unfortunately,  for  the  present  I  think  the  unbiased  observer 
must  conclude  that  the  specific  method  of  treatment  is  still  experimental, 
and  is  not  to  be  relied  upon  to  the  exclusion  of  other  methods. 

3.  The  surgical  treatment.  We  owe  our  present  knowledge  of  tuber- 
culosis of  the  kidney  not  so  much  to  the  internist,  who  docs  not  have  the 
opportunity  of  seeing  the  diseased  kidney,  nor  to  the  pathologist,  who  sees 


182  SIXTH    INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

the  tuberculous  kidney  in  the  dead,  as  to  the  general  surgeons  and  the  surgical 
specialists  who  have  had  the  opportunity  of  examining  the  tuberculous 
kidney  and  ureter  and  bladder  in  the  living,  and  who  have  been  able  to  follow 
these  cases  and  watch  the  results  of  the  various  operations  which  have  been 
undertaken  for  the  cure  of  the  disease. 

It  is  to  these  men  we  must  go  for  the  literature  on  kidney  tuberculosis: 
Albarran,  Tuffier,  Israel,  Kiimmel,  Garre,  Kapsammer,  Willy  Meyer,  Walker, 
Morris,  and  others.  Among  these  we  find  a  fairly  unanimous  agreement 
that  kidney  tuberculosis  is  a  hematogenous  infection.  That  it  is  early  uni- 
lateral, that  when  it  is  early  diagnosed,  it  can  be  cured  by  the  removal 
of  the  focus  of  disease,  i.  e.,  by  a  nephrectomy. 

The  nephrotomies  and  drainage,  which  were  undertaken  in  the  early  de- 
velopment of  this  work,  effected  few  if  any  cures,  and  as  a  result  nephrotomy 
for  kidney  tuberculosis  has  been  abandoned,  except  as  a  preliminary  oper- 
ation, in  cases  of  mixed  infection  where  the  condition  of  the  patient  does  not 
permit  of  an  immediate  nephrectomy.  Resection  of  the  portion  of  the  kidney 
grossly  involved  has  also  been  abandoned,  because  the  operation  gave  few 
cures  and  because  a  careful  study  of  the  pathological  anatomy  shows  that 
there  are  usually  so  many  foci  present  that  resection  offers  little  hope  of 
cure. 

Primary  nephrectomy  for  early  unilateral  kidney  tuberculosis  can  be 
done  with  less  than  5  per  cent,  of  mortality.  In  Kiimmel's  last  series,  69 
cases,  the  mortality  was  but  2.7  per  cent.,  and  with  the  prospect  of  perma- 
nently curing  about  80  per  cent.  An  interesting  and  important  fact  in 
connection  with  these  operations  is  that  the  limited  bladder  tuberculosis, 
which  is  so  constant,  is  gradually  fully  recovered  from  after  the  removal 
of  the  primary  focus,  i.  e.,  the  kidney.  In  the  light  of  our  present  knowl- 
edge, then,  we  must  conclude  that  in  unilateral  renal  tuberculosis  early 
nephrectomy  is  the  best  treatment.  This  should  be  combined  with  the 
well-recognized  hygienic  treatment  of  tuberculosis. 

In  bilateral  renal  tuberculosis  the  treatment  should  be  the  hygienic 
treatment  plus  the  specific  treatment  with  tuberculin,  until  at  least  the 
value  of  this  method  has  been  proved  or  disproved,  and  in  some  cases,  where 
especially  indicated,  such  palliative  surgical  measures  as  nephrotomy  and 
drainage  may  be  of  service. 

These  well-established  facts  in  regard  to  kidney  tuberculosis  should  be 
widely  known: 

1.  Kidney  tuberculosis  is  comparatively  common. 

2.  It  is  at  first  unilateral. 

3.  An  early  diagnosis  is  possible. 

4.  It  can  be  cured  in  its  early  stages  by  appropriate  treatment. 


THE  SURGICAL  FORMS  OF  INTESTINAL 
TUBERCULOSIS. 

By  Dr.  Henry  Hartmann, 

Surgeon  to  Bichat  Hospital ;    Associate  Professor  of  Surgery  to  the  Faculty,  Paris. 


The  history  of  the  surgical  aspect  of  intestinal  tuberculosis  is  compara- 
tively recent.  One  might  almost  say  that,  up  to  the  present  period,  the 
ulcerous  enteritis  of  consumptive  patients  was  alone  known.  Intestinal 
tuberculosis  was  considered  as  a  sequence  of  pulmonary  tuberculosis,  ul- 
ceration of  the  intestine  and  death  of  the  patient  being  its  constant  ending. 
Primary  tuberculosis  of  the  intestine  was  hardly  admitted,  direct  infection 
of  the  intestinal  mucous  membrane  by  food  having  been  proved  only  re- 
cently through  the  investigations  of  Chauveau  and  Arloing.  The  surgeon's 
task  was,  therefore,  hmited  to  the  opening  of  encysted  suppurations  in 
contact  with  the  ulcerated  intestine.  French  pathologists  had,  however, 
demonstrated  that  tuberculosis  did  not  tend  to  caseation  and  ulceration 
alone,  but  could  also  produce  sclerosis;  and  Grancher  expressed  this 
opinion  tersely  by  saying  that  the  tendency  of  tuberculosis  was  fibroca- 
seous. 

During  the  same  period  the  improvement  of  abdominal  surgery,  dimin- 
ishing its  risks,  caused  operators  to  open  the  abdomen  without  a  precise 
diagnosis  in  cases  that  were  not  amenable  to  medical  treatment,  and  to 
discover  in  that  way  lesions  due  to  tuberculosis  which  surgery  alone  could 
cure :  I  mean  cicatricial  stenosis  of  the  intestine. 

At  the  same  time  a  more  thorough  investigation  of  certain  lesions, 
formerly  considered  as  cases  of  mahgnant  disease  of  the  intestine  or  inflam- 
matory stenosis,  revealed  the  existence  of  hypertrophic  or  inflammatory 
tuberculosis  of  the  intestine. 

Finally,  appendicitis  itself  was  proved  to  be,  in  a  certain  number  of 
cases,  a  bacillary  lesion.  Leaving  aside  the  last  named,  we  will  limit  our- 
selves to  the  following  three  points : 

1.  Perforations. 

2.  Fibrous  stenosis. 

3.  Hypertrophic  tuberculosis. 

183 


184  sixth  international  congress  on  tuberculosis. 

1.  Intestinal  Perforations. 

They  are  more  commonly  located  on  the  ileum,  sometimes  on  the  cecum 
and  appendix,  much  more  seldom  on  the  ascending  colon  and  duodenum,  as 
shown  by  the  statistics  of  Fen  wick  and  Dodwell.  The  perforation  can  take 
place  without  the  previous  formation  of  adhesions,  causing  general  peri- 
tonitis. Habitually,  however,  adhesions  exist,  perforation  takes  place  into 
a  space  walled  off  by  them,  and  may  even  bring  about  anastomosis  with 
another  loop  of  the  intestine  or  some  other  hollow  organ,  such  as  the  bladder. 
Habitually,  an  abscess  forms,  which  ulcerates  the  sldn  and  brings  about  a 
pyostercoral  fistula. 

In  case  of  general  peritonitis,  operation  hardly  seems  to  have  given  any 
results;  in  the  second  case,  on  the  contrary,  a  wide  opening  of  the  cavity 
has  cured  some  cases;  the  communication  between  the  intestinal  loops  can 
close  of  itself,  as  we  have  ourselves  been  able  to  observe.  If  a  pyostercoral 
fistula  persists,  a  second  operation  becomes  possible  when  the  patient's 
general  condition  has  improved,  and  he  may  be  cured  by  resection  or  ex- 
cision of  the  affected  loop,  according  to  the  case. 

2.  Cicatricial  Stenosis  of  the  Intestines. 

Their  habitual  location  is  the  small  intestine,  especially  toward  its  ending. 
Certain  exceptional  cases  of  subcutaneous  stenosis  of  the  intestine,  probably 
due,  according  to  Darier,  to  sclerosis  of  lymphatic  tuberculosis,  may  be  con- 
veniently put  under  the  same  heading. 

Felix  finds,  from  the  examination  of  72  cases,  that  9  per  cent.'are  situated 
in  the  first  third  of  the  small  intestine,  17.8  per  cent,  in  the  second,  and 
73.2  per  cent,  in  the  third.  The  scar  is  transverse,  perpendicular  to  the 
axis  of  the  intestine,  as  was  the  ulceration  which  preceded  it.  It  forms  a 
band — a  valve — but  hardly  extends  lengthwise;  the  gut  looks  as  though  it 
had  been  tied  with  a  string.  The  stricture  is  more  or  less  tight;  sometimes 
it  is  hardly  marked;  in  others  it  will  only  admit  a  pencil  or  even  a  catheter. 
Exceptionally  there  is  but  one;  usually  there  are  several  strictures,  maldng  the 
affected  coil  look  like  a  pearl  necklace  or,  when  they  are  more  distant,  like 
a  string  of  sausages,  to  use  a  comparison  often  met  with  in  German  authors. 
Sometimes  the  distance  separating  the  strictures  is  very  great. 

Above  the  narrowed  point,  the  gut  is  dilated;  at  the  same  time  its  coats 
are  modified.  Patel,  who  has  studied  these  lesions  well,  says  that  when  the 
tuberculous  process  is  not  extinguished,  the  specific  alterations  spread  to 
the  segment  above;  the  wall  is  thickened  by  embryonal  infiltration,  with 
disseminated  tubercles,  especially  in  the  submucous  layer;  in  cases  of  pure 
stenosis,  on  the  contrary,  when  the  specific  process  is  extinct,  the  wall  of 
the  gut  is  thin,  and  the  muscular  layer  atrophic. 


SURGICAL   FORMS    OF    INTESTINAL  TUBERCULOSIS. — HARTMANN.  185 

From  what  we  have  seen  a  sharp  distinction  should  be  made  between 
tuberculous  stenosis  of  the  large  and  the  small  intestine.  Whereas  the  first 
only  gives  rise  to  slight  alterations  of  the  segment  situated  above,  in  the 
second  we  find  dilatation  and  hypertrophy  to  such  a  degree  that  sometimes 
the  gut  resembles  a  stomach.  In  case  of  multiple  stenosis  of  the  small 
intestine,  all  the  parts  situated  above  the  lowest  stenosis  are  thickened  and 
dilated. 

3.  Hypertrophic  or  Inflammatory  Tuberculosis. 

For  a  long  time  it  was  confounded  with  malignant  tumors;  we  estab- 
lished a  clear  distinction  between  them  in  a  paper  published  with  Fillet  in 
1891. 

First  observed  on  the  cecum,  its  habitual  location,  this  form  of  tuber- 
culosis has  since  then  been  the  subject  of  numerous  articles.  Sourdille, 
then  Toupet  and  I,  have  shown  that  many  cases  of  so-called  syphilitic 
stenosis  of  the  rectum  were  due  to  it.  It  was  afterward  described  by 
Schiller  on  the  descending  colon,  by  Konig  and  Eiselsberg  on  the  transverse 
colon. 

Often  tuberculosis  of  the  ascending  colon  associates  with  tuberculosis 
of  the  cecum  (Lartigues),  that  of  the  sigmoid  fliexure  with  tuberculosis  of  the 
rectum  (Mayo  Robson),  Lastty,  multiple  hypertrophic  tuberculosis  of  the 
large  intestine  may  be  met  with  (Besangon  and  Lapointe,  Gross,  Hartmann). 
A  certain  number  of  cases  have  been  observed  on  the  small  intestine;  but, 
instead  of  being  mostly  near  its  ending,  as  is  the  case  with  scar-stenosis, 
they  rather  concern  the  jejunum,  according  to  Berande  and  Patel.  MacCosh 
and  Thacher  have  pubhshed  a  fine  example  of  this. 

IMikulicz,  Mayo  Robson,  and  Margaruci  have  related  exceptional  cases  of 
hypertrophic  tuberculosis  of  the  duodenum. 

The  striking  fact,  in  all  these  cases,  is  the  thickening  of  the  parts — such  a 
thickening  that  it  leads  one  to  think  of  a  tumor  proper,  all  the  more  so  as  the 
affected  part  is  in  most  cases  surrounded  by  a  mass  of  sclerotic  fat.  In 
contradistinction  to  scar-stenosis,  this  form  of  tuberculosis  extends  over 
a  certain  distance;  the  caliber  is  markedly  diminished,  the  ulcerated  mucous 
membrane  bearing  polypoid  growths.  Under  the  microscope  the  lesions 
differ  from  ordinary  tuberculosis,  inasmuch  that,  while  there  are  specific 
lesions,  often  but  little  developed,  there  exists,  at  the  same  time,  other  le- 
sions, consisting  chiefly  in  diffuse  embryonal  infiltration,  mostly  marked  in 
the  submucous  and  subserous  layer.  These  inflammatory  lesions  are  so 
marked  that,  in  our  first  observation,  we  felt  obliged  to  speak  of  tubercu- 
lous typhlitis.  This  character  is  also  clearly  marked  when  the  rectum  is 
affected. 


186  sixth  international  congress  on  tuberculosis. 

4.  Symptoms,  Diagnosis,  Complications. 

The  symptoms  depend  more  upon  the  location  (small  or  large  intestine) 
than  upon  the  nature  of  the  alterations  (stenotic  or  hypertrophic).  Stenosis 
of  the  small  intestine,  after  a  period  one  might  call  medical,  marked  by  vague 
gastro-intestinal  trouble  (laborious  digestion,  vomiting,  irregular  stools), 
soon  makes  itself  noticed  by  more  characteristic  symptoms,  especially  if 
it  is  situated  near  the  end  of  the  ileum,  as  is  the  rule. 

Two  or  three  hours  after  eating  the  patient  is  seized  with  a  violent  pain, 
that  increases  gradually  and  is  accompanied  by  a  tumefaction  in  the  painful 
spot.  After  a  few  moments  the  pain  reaches  its  zenith,  when  suddenly 
musical  sounds  are  heard,  the  tumefaction  collapses,  and  the  pain  ceases. 
In  short,  one  meets  the  group  of  symptoms  described  by  Konig  in  intestinal 
stenosis.  Peristaltic  undulation  of  the  gut,  splashing  of  the  distended  loop, 
are  also  good  signs.     Rarely,  a  tumor  is  felt. 

Tuberculosis  of  the  large  intestine  has  very  different  symptoms.  There 
are  no  musical  sounds,  no  splashing  loop;  but  in  most  cases  one  finds  a 
hard  tumor,  which  is  from  time  to  time  the  seat  of  inflamm-ation,  resembling 
appendicitis  or  sigmoiditis,  as  the  case  may  be.  Sometimes,  even,  inflamma- 
tion goes  further :  an  abscess  forms,  which  may  lead  to  pyostercoral  fistula. 

An  absolute  diagnosis  is  usually  impossible.  Tuberculosis  must  be  sus- 
pected when  the  symptoms  we  have  described  are  chronic  and  exist  in  a 
young  subject.  One  must  not  attach  undue  importance  to  the  condition  of 
the  lungs,  surgical  forms  of  intestinal  tuberculosis  generally  not  associating 
with  pulmonary  consumption,  as  does  medical  tuberculous  enteritis.  In 
most  cases  one  only  finds  slight  and  torpid  lesions;  these  are  so  common, 
in  Paris  at  least  (70  per  cent,  of  the  patients),  that  their  presence  is  no  clue 
to  the  specific  nature  of  a  lesion  in  another  part  of  the  body. 

Complications  of  various  nature  may  occur  in  surgical  forms  of  intestinal 
tuberculosis.  Perforation  is  exceptional,  these  forms  corresponding  either 
to  healed  lesions  or  hypertrophic  inflammation,  in  which  the  coats  of  the 
intestine  thicken  and  are  even  doubled  in  most  cases  by  scleroadiposis. 
Acute  occlusion  has,  on  the  contrary,  been  ol3served  a  certain  number 
of  times;  it  results  either  from  the  evolution  of  the  stricture  itself,  or  from 
adhesions  or  sharp  bendings  of  the  intestine.  One  has  also  seen  occlusion 
result  from  mere  spasm  of  the  intestine  localized  at  the  seat  of  the  ulcera- 
tion, which  explains  a  few  cures  effected  by  mere  celiotomy.  Finally, 
occlusion  may  result  from  intussusception,  of  which  B(3rard  has  collected 
seven  cases. 

5.  Treatment. 
Divers  operations  have  been  made.     Simple  celiotomy  has  given  some 
good  results,  either  by  dispelling  the  spasm  that  often  aggravates  the  stric- 


SURGICAL   FORMS    OF   INTESTINAL   TUBERCULOSIS. — HARTMANN.         187 

ture,  or  by  modifying  in  a  happy  way  tuberculous  lesions  that  were  still 
in  active  evolution.  Plastic  operations,  identical  in  their  principle  with 
those  practised  on  the  pylorus,  have  seldom  been  made. 

The  ideal  treatment  consists  in  resection,  for  alone  it  surely  does  away 
with  the  tuberculous  focus,  the  regression  of  which  is  not  certain  with  other 
methods.  Unfortunately,  it  is  not  always  possible,  OMdng  to  the  patient's 
general  condition  prohibiting  a  serious  operation,  or  on  account  of  local 
conditions  (extensive  and  tough  adhesions,  disseminated  tuberculous  lesions 
of  the  peritoneum,  involvement  of  numerous  lymphatic  glands,  strictures 
widely  distant  one  from  another,  etc.). 

One  must  then  resort  to  an  indirect  mode  of  treatment,  which  gives 
much  better  results  than  in  cancer,  for  tuberculous  lesions  may  regress, 
whereas  those  of  cancer  are  fatally  progressive. 

Side-to-side  anastomosis  constitutes  the  simplest  mode  of  indirect  treat- 
ment; it  should  be  used  when  the  general  condition  demands  a  short  opera- 
tion; its  drawback  is  that  it  imperfectly  divests  the  contents  of  the  in- 
testine. It  is,  therefore,  inferior  to  unilateral,  and  especially  bilateral, 
exclusion  of  the  intestine;  this  last  operation  has  the  advantage  of  completely 
suppressing  the  passage  of  fecal  matter  through  the  cUseased  gut.  It  may  be 
combined  with  fistulization,  so  as  to  evacuate  the  secretions  of  the  loop. 
These  indirect  operations  often  suffice  to  improve  the  condition  of  the 
patient,  and  secondarily  the  local  status,  in  such  a  way  that  a  secondary 
excision  becomes  possible  and  may  then  be  performed  without  danger. 

In  case  of  complete  occlusion,  with  intestinal  paralysis,  enterotomy  may 
be  the  only  thing  feasible;  one  is  obliged  to  resort  to  it  notwithstanding  its 
seriousness,  which  increases  as  the  point  of  the  gut  that  must  be  opened 
becomes  more  proximal.  In  order  not  to  be  placed  in  this  plight,  one  must 
not  put  off  the  operation  in  cases  of  chronic  stenosis  of  the  intestine;  one 
must  interfere  before  the  period  of  complete  occlusion,  before  the  strength 
of  the  patient  fails,  before  his  nutrition  is  impaired.  Early  interference 
alone  can  meet  with  the  success  we  have  a  right  to  expect. 


TUBERCULOSIS    OF    THE    FEMALE    GENERATIVE 

ORGANS. 

By  Dr.  I.  S.  Stone, 

Washington. 


Dr.  Stone  gave  a  demonstration  of  pathological  specimens,  with  a  dis- 
cussion of  the  subject.     His  conclusions  were  as  follows: 

The  vast  majority  of  tubercular  diseases  of  these  organs  are  secondary. 

This  does  not  mean  that  the  primary  seat  or  point  of  entrance  of  the 
infectious  process  is  either  visible  or  to  be  discovered  by  the  most  careful 
search. 

Repeated  experiments  and  observations  fail  to  establish  a  definite  method 
by  which  tuberculosis  selects  any  organ,  such  as  the  uterine  adnexa,  for  the 
implantation  of  the  morbid  process. 

It  is  our  experience  to  find  numerous  instances  of  "mixed  infection," 
but  we  do  not  think  a  previous  infection  invites  the  implantation  of  tuber- 
cular disease. 

Proof  of  the  direct  entrance  of  tubercle  bacilli  through  the  vagina  into 
the  uterus,  and  thence  to  the  tubes  and  peritoneum,  has  not  been  obtained. 

Some  gynecologists  are  inclined  to  believe  that  many  of  the  erosions  of 
the  cervix  in  virgins  attended  with  leukorrhea  are  due  to  an  invasion  of  the 
disease  in  question. 

A  diagnosis  of  genital  tuberculosis,  by  one  of  the  methods  of  using  Koch's 
tuberculin,  has  rarely  been  tried.  As  many  of  the  cases  are  associated  with 
peritoneal  tuberculosis,  such  inoculations  have  been  reserved  for  the  more 
extended  ravages  of  the  disease. 

The  frequency  of  genital  tuberculosis  cannot  be  precisely  stated,  be- 
cause tedious  and  prolonged  section  work  is  necessary  in  many  instances 
before  a  diagnosis  can  be  established. 

The  median  incision  is  advised,  through  which  the  peritoneum,  mesentery, 
and  perhaps  other  abdominal  contents  may  be  examined  and  treated  by 
such  operative  procedures  as  are  required. 

This  method  is  to  be  recommended  highly,  because  it  is  possible  that 
tuberculosis  of  intestine  and  peritoneum  may  readily  be  overlooked  if  vaginal 
operation  is  practised. 

The  curative  results  of  hysterectomy,  salpingectomy,  and  oophorectomy 
are  nearly  always  satisfactory,  when  there  is  but  little  extension  of  the  morbid 
process  to  other  organs. 

188 


TUBERCULOSIS  OF  THE  PERITONEUM. 

By  Dr.  F.  C.  Lund, 

Boston. 


The  insidious  nature  of  tuberculous  peritonitis,  the  manifold  forms  in 
which  it  may  appear,  and  the  many  conditions,  both  acute  and  chronic, 
which  it  may  simulate,  make  it  a  condition  of  great  interest  both  to  the  ab- 
dominal surgeon  and  the  internist.  Often  acute  in  its  early  manifestations, 
it  may  be  and  is  mistaken  for  acute  appendicitis,  and  the  operation  alone 
reveals  the  nature  of  the  chagnosis.  Again,  in  its  chronic  form,  it  may  run 
a  latent  course  until  perforation  of  a  tuberculous  ulcer  precipitates  the 
picture  of  an  acute  fulminating  peritonitis.  The  contraction  of  the  scar  of 
a  healed  ulcer,  or  the  bands  and  kinks  resulting  from  adhesions,  may  cause 
acute  intestinal  obstruction,  with  all  its  terrors,  in  a  case  where  the  real  but 
unsuspected  cause  is  tuberculous  peritonitis. 

Statistical  studies  of  tuberculous  disease  have  been  many.  Grawitz  and 
Brunn,  in  particular,  have  published  statistics  of  13,422  autopsies  in  Ger- 
many; Cummins,  of  3405  in  Philadelphia,  etc.  The  consensus  of  opinion 
is  that  tuberculous  peritonitis  is  found  in  3  per  cent,  of  all  autopsies, 
and  that  males  are  affected  in  comparison  with  females  in  proportion  of 
two  to  one.  Here  autopsy  statistics  show  a  wide  variance  from  surgical 
statistics.  Surgeons  find  the  proportion  of  females  to  males  is  about  two 
to  one.  More  males  are  autopsied  than  females,  more  females  are  laparot- 
omized  than  males;  autopsies  show  terminal  conditions,  laparotomies, 
fortunately,  earlier  stages.  Both  laparotomies  and  autopsies  reveal  un- 
suspected peritoneal  tuberculosis,  in  the  latter  case,  usually  accompanied  by 
tuberculosis  elsewhere.  Neither  laparotomies  nor  autopsies  give  any  idea 
of  the  large  number  of  cases  which  run  a  latent  course  and  are  never  dis- 
covered. 

In  three  cases  of  operation  for  radical  cure  of  hernia  in  children,  and  in 
one  case  of  perforating  gangrenous  appendicitis  (streptococcus)  in  an  adult, 
I  have  found  tuberculous  peritonitis  present  at  the  operation.  All  the 
patients  had  been  well  previous  to  the  operation  or  attack,  and  remained 
well  afterward.  In  these  particular  cases  I  should  think  it  hardly  fair  to 
attribute  cure  to  laparotomy,  and  feel  that,  without  laparotomy,  they  might 
have  run  their  course  unsuspected. 

189 


190  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

Another  case  of  interest  in  this  connection  was  operated  upon  by  another 
surgeon  for  acute  appendicitis  with  gangi-ene.  The  records  stated  that  the 
appendix  had  been  removed,  A  sinus  which  refused  to  heal  followed  the 
operation,  and  some  months  afterward  I  removed  about  three  inches  more 
of  appendix,  which,  on  examination  by  the  pathologist,  proved  to  be  tuber- 
culous. At  this  second  operation,  owing  to  the  number  of  adhesions  and  a 
tuberculosis  not  being  suspected  at  the  time,  no  investigation  was  made  of 
the  condition  of  the  general  cavity.  The  patient  succumbed  about  a  year 
afterward  to  a  tuberculous  peritonitis. 

Statistics  as  to  the  source  of  the  peritoneal  infection  are  equally  un- 
satisfactory. Primary  peritoneal  tuberculosis,  however,  rarely  occurs. 
Although  we  may  conceive  the  entrance  of  bacilli  through  the  genital  pass- 
ages into  the  peritoneum  direct,  without  the  presence  of  a  lesion  in  the  genital 
tract,  and  although  it  has  been  experimentally  found  that  bacilli  may  pass 
through  the  intestinal  mucous  membrane  and  reach  the  peritoneum  without 
causing  a  local  lesion  of  the  former,  such  an  entrance  is  the  exception,  rather 
than  the  rule.  In  the  majority  of  cases  of  peritoneal  tuberculosis  in  the 
female  the  peritonitis  begins  around  the  end  of  a  tuberculous  Fallopian  tube, 
and  in  the  male  about  a  tuberculous  ulcer  of  the  appendix,  cecum,  or  small 
intestine.  The  genital  route  of  entrance  accounts  for  the  larger  proportion 
of  surgical  cases  in  females  than  in  males.  Swallowed  bacilli  from 
pulmonary  tuberculosis  and'  infected  milk  and  food  account  for  the 
various  forms  of  intestinal  tuberculosis.  A  consideration  of  tuberculous 
peritonitis,  entirely  apart  from  tuberculosis  of  the  female  genitals  and  the 
intestinal  tract,  cannot  be  made,  so  close  are  the  etiological  and  pathological 
associations.  The  genito-urinary  tract  is  an  occasional  source  of  infection, 
and  more  rarely  the  lymphatic  current  from  the  pleura  or  mesenteric  or 
mediastinal  glands;  still  more  rarely,  the  blood-current. 

The  disease  is  frequent  during  childhood,  but  most  frequent  between 
the  ages  of  twenty  and  thirty  years. 

Varieties. — Aside  from  the  mixed  infections  which  are  sometimes  given 
as  a  fourth  or  suppurative  form,  we  find  that  the  various  types  of  tuber- 
culous peritonitis  are  best  classified  under  Osier's  three  forms: 

1.  Serous,  exudative,  or  miliary  form. 

2.  Nodular  or  ulcerative  form. 

3.  Adhesive,  fibroplastic,  or  cystic  form. 

These  three  forms,  however,  grade  into  one  another  gradually  and  im- 
perceptibly, and  between  them  there  is  no  definite  line. 

All  three  have,  as  a  usual  origin,  a  local  peritonitis  of  the  miliary  variety, 
with  exudation.  This  miliary  tuberculosis  most  commonly  spreads  over  the 
greater  portion  of  the  peritoneal  cavity,  and  is  accompanied  with  ascites; 
the  omentum  and  small  intestines  are  pushed  by  the  exudate  into  the  upper 


TUBERCULOSIS   OF   THE    PERITONEUM. — LUND.  191 

part  of  the  cavity;  the  omentum  becomes  curiously  rolled  up  and  thickened, 
and  may  be  felt  as  a  transverse  cord  extending  across  the  upper  portion  of 
the  cavity  along  the  border  of  the  transverse  colon.  The  coils  of  small 
intestine  may  and  do  become  adherent  to  each  other,  thickened,  and  fused 
into  a  mass,  which  may  also  be  felt  as  a  tumor  in  the  upper  part  of  the  ab- 
domen when  it  is  pushed  up  by  the  fluid  exudate,  the  fibroplastic  process 
being  a  terminal  form  of  the  miliary  tuberculosis  which  causes  the  exudate. 
The  endothelial  layer  of  the  peritoneum  is  destroyed,  and  the  adjacent  coils 
of  intestine  become  adherent  by  connective  tissue  of  varying  forms,  from  the 
"soft,  spider-web  or  fuzz-like  agglutinations"  described  by  Murphy,  to  more 
glistening,  edematous,  inflamed  peritoneum  or  even  highly  organized  con- 
nective tissue. 

Nodular  Form. — The  nodular  or  ulcerative  variety  is  described  by  Mur- 
phy as  a  localization  of  the  tuberculous  process  to  numerous  small  areas, 
these  areas  including  not  only  the  peritoneal  coat,  but  the  deeper  structures, 
such  as  the  intestinal  wall,  mesentery,  uterus,  and  ovaries,  destroying  the 
latter  perhaps,  and  changing  them  into  caseous  masses,  causing  ulceration 
or  perforation  of  the  intestine,  with  either  a  localized  or  general  peritonitis 
according  to  the  condition  present.  In  this  form  it  will  be  readily  seen  that 
mixed  infection  may  complicate  the  picture. 

Fibroplastic  Form. — When  the  fibroplastic  process  becomes  general, 
we  have  the  adhesions  of  the  intestines  to  the  abdominal  wall,  as  well  as  to 
each  other,  the  obliteration  of  the  abdominal  ca\ity,  and  the  development 
of  the  full-fledged  fibroplastic  variety  of  the  disease.  Circumscribed  areas 
of  the  peritoneum  not  becoming  involved  in  the  fibroplastic  adhesions  re- 
act to  produce  fluid,  and  become  surrounded  by  the  adherent  coils,  produc- 
ing localized  cysts.  These  cysts  may  become  subject  to  mixed  infections 
or  suppuration. 

Symptoms  and  Physical  Signs. — ^These  will  vary  with  the  point  of 
origin,  type,  acuteness  or  chronicity,  and  complications  of  the  disease.  In 
the  commonest  form  arising  from  tuberculous  salpingitis  we  have  recurrent 
attacks  of  pelvic  pain,  \sdth  more  or  less  fever,  not  so  acute,  however,  as  in 
the  gonorrheal  or  septic  salpingitis.  Menstrual  irregularity  is  not  marked. 
The  tumor  is,  of  course,  felt  behind  the  uterus,  diagnosticated  as  a  tube,  and 
operated  upon.  The  tuberculous  process  may  be  entirely  confined  to  the 
tube,  and  although  we  find  it  reddened  and  adherent,  with  cheesy  masses  in 
its  interior,  there  may  be  no  peritoneal  tuberculosis  about.  On  the  other 
hand,  the  miliary  tubercles  and  ascites  may  involve  the  lower  portion  or 
even  the  whole  of  the  peritoneum;  or,  the  fibroplastic  form  prevailing, 
there  may  be  the  greatest  difficulty  in  digging  out  the  adherent  tubes  from 
the  masses  of  adherent  intestine  which  surround  and  cover  them. 

Where  there  is  no  pelvic  pain  or  tubal  tumor,  we  are  left  in  doubt  before 


192  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

operation  as  to  the  origin  of  the  disease,  and  the  general  symptoms  are  more 
prominent  than  the  local.  The  same  is  true  in  regard  to  the  cases  of  in- 
testinal or  appendicular  origin.  We  have  here  sometimes  a  large  tumor, 
due  to  the  swollen,  edematous  cecum,  and  its  accompanying  mesenteric 
glands,  with  fever  and  bloody  diarrhea,  the  tuberculous  enteritis,  which  may 
or  may  not  be  accompanied  by  the  miliary  tuberculosis  with  ascites,  some- 
times, as  is  more  common,  the  insidious  onset  of  the  miliary  tuberculosis, 
with  no  definite  localizable  focus  of  infection,  in  which  the  general  symptoms 
predominate  over  the  local,  often  to  the  exclusion  of  the  latter.  Of  these 
general  cases  the  miliary  ascitic  variety,  the  chronic  form,  is  commonest. 
Here  belong  the  larger  number  of  cases  which  are  admitted  to  the  medical 
wards  for  ascites,  and  upon  which  the  surgeon  is  sometimes  asked  to  exercise 
his  skill.  In  these  cases  there  are  usually  abdominal  pain,  mild  fever,  and 
gradual  enlargement  of  the  abdomen  from  fluid.  Emaciation  and  anemia 
may  or  may  not  be  present.  The  diagnosis  is  frequently  made  by  the  pres- 
ence of  a  gradually  increasing  ascites  in  a  young  or  middle-aged  patient, 
without  heart  disease  or  any  other  cause  for  the  abdominal  fluid.  A  can- 
cerous peritonitis  is  naturally  sometimes  impossible  to  distinguish  from  the 
tuberculous  variety,  but  the  age  of  the  patient  and  cachexia,  or  the  presence 
of  a  known  primary  intra-abdominal  focus,  will  usually  suffice. 

Young  patients  with  gradually  increasing  ascites  and  vague  abdominal 
pains  usually  have  tuberculous  peritonitis.  The  surgeon  who  does  not  al- 
ways think  of  tuberculous  peritonitis  in  all  doubtful  abdominal  cases  with 
general  enlargement  will  frequently  be  disappointed  in  diagnosis. 

In  sharp  contradistinction  to  this  variety  is  the  acute  form  of  tubercu- 
lous peritonitis.  This  is  fortunately  rare,  but  in  its  acute  origin  and  sudden 
onset  may  and  does  simulate  acute  appendicitis  and  leads  to  immediate 
operation.  These  acute  peritoneal  symptoms  have  in  one  case  of  my  own 
led  to  early  laparotomy  and  the  revealing  of  the  condition  of  a  tuberculous 
peritonitis  at  an  early  stage  before  tubercles  had  appeared.  This  prevented 
my  making  the  diagnosis  at  the  time,  and  when,  unaffected  by  the  laparot- 
omy, the  disease  went  on  from  the  acute  to  the  chronic  nodular,  ulcerative 
form,  with  long-continued  fever  mistaken  at  first  for  typhoid,  great  per- 
plexity ensued,  and  the  diagnosis  was  not  suspected  till  shortly  before 
death,  nor  made  until  the  autopsy.  The  case  presents  so  many  points 
of  interest  that  it  seems  worth  abstracting  here: 

A  girl  of  thirteen  years  had  been  ill  for  ten  days  with  abdominal  pain 
and  vomiting.  She  had  previously  been  a  delicate  child,  but  was  attending 
school  regularly  until  one  week  before  I  saw  her,  when  she  had  had  an  attack 
of  abdominal  pain  which  kept  her  home  from  school  for  one  day.  I  found 
a  thin,  delicate-looking  girl,  with  a  temperature  of  104°  F.,  pulse  120  and  of 
good  quality,  tongue  moist,  color  and  general  appearance  good,  abdomen 


TUBERCULOSIS   OF   THE   PERITONEUM. — LUND.  193 

everywhere  tender,  but  no  muscular  spasm.  On  account  of  the  absence  of 
spasm,  high  temperature,  and  general  good  appearance,  the  case  was  thought 
not  to  be  acute  appendicitis  until  two  days  later,  when  general  abdominal 
spasm  as  well  as  tenderness  were  present;  the  temperature  was  103°  F.,  and 
the  child  looked  worse.  Tubal  infection  was  thought  of,  and  the  vulva  and 
urethra  carefully  examined  for  redness  and  discharge,  not  the  slightest 
evidence  of  either  being  found.  Median  laparotomy  below  the  umbilicus 
showed  a  greatly  injected,  thickened,  purplish  peritoneum.  The  cavity 
contained  considerable  dark,  thick,  greenish  serum.  The  injection  was 
greatest  about  the  Fellopian  tubes  in  the  pelvis,  and  the  lower  portion  of 
the  omentum,  which  lay  in  the  bottom  of  the  pelvis  in  contact  ^\'ith  the  tubes, 
had  on  it,  when  drawn  up,  a  few  flakes  of  fresh  fibrin.  The  tubes,  while 
purplish  and  injected,  were  not  distended  and  contained  no  pus.  The 
appendix  was  gi-eatly  injected,  and  contained  a  large  concretion  in  the  tip. 
It  v/as  removed,  and  the  mucous  meml^rane  throughout  was  found  to  be 
pale  and  normal,  the  inflammation  being  confined  to  the  peritoneal  covering. 
No  sign  of  a  tubercle  could  be  found  anywhere  in  the  peritoneal  surface. 
After  evacuation  of  the  fluid  the  abdomen  was  sutured  without  drainage. 
The  girl's  symptoms  improved  at  first,  but  the  temperature  ran  for  six  weeks 
from  101°  or  102°  F.  at  night  to  normal  or  subnormal  in  the  forenoon.  There 
was  slight  diarrhea.  Negative  Widal  excluded  typhoid.  The  abdomen 
gradually  distended,  and  individual,  thickened,  distended  coils  could  be 
felt  in  various  parts  of  it.  The  girl  went  home  and  was  up  and  about  for 
several  weeks.  Then  great  induration  of  the  abdominal  wound  developed, 
followed  by  abscess,  opening,  foul  discharge,  fecal  fistula,  and  death  six 
months  after  the  operation. 

Aidopsy. — Miliary  tuberculosis  of  the  mucous  membrane  of  the  uterus. 
Marked  general  miliary  tuberculosis  of  the  peritoneum,  with  adherent 
intestines  surrounding  caseous  masses,  and  general  enlargement  and  caseation 
of  the  mesenteric  glands.     Fecal  fistula  in  lower  portion  of  ileum. 

We  had  here  a  case  of  acute  tuberculosis  of  the  peritoneum  in  a  young 
girl,  secondary  to  tuberculosis  of  the  uterus,  ending  in  the  chronic  nodular 
form,  mixed  infection,  and  death.  Murphy  has  called  attention  to  the  fact 
that  tuberculosis  of  the  uterus  is  usually  found  in  childhood  and  old  age, 
before  and  after  the  menopause.  During  the  menstrual  life,  when  the  uter- 
ine mucous  membrane  is  shed  every  month,  it  is  almost  unknown,  while 
tubal  tuberculosis  is  common.  How  the  bacilli  reached  this  girl's  uterus  is 
a  puzzle.  It  seems  as  if  they  must  have  been  introduced  through  the  vagina. 
The  lungs  and  other  portions  of  the  body  at  the  autopsy  were  normal.  The 
case  was  of  great  interest  to  me,  first,  from  the  simulation  of  acute  appen- 
dicitis, and,  second,  from  the  opportunity  to  examine  and  note  the  appear- 
ance of  an  acute  tuberculosis  of  the  peritoneum  before  the  tubercles  appeared. 
A  thickening,  edema,  and  dull  purplish  congestion,  with  dark-greenish  fluid, 
were  the  conditions,  only  a  very  little  fibrin  in  small,  dark-yellow,  soft, 
translucent  flakes  being  present,  and  that  in  the  bottom  of  the  pelvis,  where, 
about  the  openings  of  the  Fallopian  tubes,  was  the  starting-point  of  the 

VOL,.    II — 7 


194  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

disease.  The  difference  between  this  and  the  bright-red  congestion,  sero- 
purulent  fluid,  and  often  abundant  opaque  fibrin  of  an  acute  septic  appen- 
dicitis was  notable. 

In  the  fibroplastic  and  nodular  forms  of  peritonitis  the  exudative  variety 
has  usually  preceded,  and  after  its  subsidence  we  are  confronted  with  the 
symptoms,  not  of  the  peritonitis  itself,  but  of  colicky  pains  due  to  obstruc- 
tion of  the  bowels  from  kinks  and  bands,  indurated,  painful  tumors  due  to 
walling  off  of  serous  or  seropurulent  exudate,  distention  of  thickened  coils 
of  intestine  which  can  be  felt  through  the  abdominal  wall,  with,  of  course, 
fever,  emaciation,  malaise,  loss  of  appetite,  and  other  corresponding  general 
symptoms.  The  frequency  of  the  development  of  tumors,  due  to  the  pres- 
ence of  swollen  and  caseated  mesenteric  and  retroperitoneal  glands,  should 
here  be  noted,  and  the  seriousness  of  the  exhaustion  and  emaciation  which 
follow  this  complication  may  readily  be  appreciated. 

In  the  cases  secondary  to  tuberculosis  of  the  intestine,  ulcers  and  stric- 
tures, due  to  internal  ulceration,  may  be  complicated  by  ascites  and  adhesions 
from  the  peritoneal  process,  and  by  edema  and  thickening  of  the  mesenteric 
glands,  etc.,  making  a  most  difficult  and  complicated  clinical  picture, 
never  twice  alike.  The  symptoms  of  intestinal  obstruction  in  the  fibro- 
plastic form  are  due  to  adhesions,  bands,  and  kinks,  and  may  be  the  first  to 
attract  attention  to  a  peritoneal  condition,  as  in  the  following  case: 

Mrs.  L.,  a  woman  of  about  thirty-five  years  of  age,  of  fair  bright  complex- 
ion, good  color,  and  fair  flesh — in  other  words,  a  healthy  looking  woman. 
She  had  suffered  for  about  two  years  with  mental  depression,  constipation, 
epigastric  pain,  backache,  nausea,  and  weakness,  beginning  with  what  was 
called  stoppage  and  followed  three  months  later  by  a  second  attack.  It  was 
said  that  she  had  vomited  blood.  She  is  said  to  have  had  a  lump  in  the 
right  hypochondrium.  Careful  examination  showed  that  the  patient  was 
a  marked  neurasthenic.  Careful  abdominal  examination  negative.  No 
evidence  of  fluid.  No  distention.  Slight  epigastric  tenderness.  Symp- 
toms of  neurasthenia  were  so  marked  in  this  case  that  the  patient  had  been 
treated  for  some  time  at  a  sanatorium.  After  talking  with  her  two  or 
three  times  I  concluded  she  was  too  sensible  to  be  a  neurasthenic,  and  that 
there  must  be  some  serious  trouble  in  the  abdomen,  although  an  exact 
diagnosis  could  not  be  made.  An  incision  through  the  upper  part  of  the 
right  rectus  exposed  the  pylorus,  gall-bladder,  and  liver.  Numerous  tu- 
bercles were  felt  on  the  liver  and  abdominal  wall.  Reaching  down  through 
the  incision  a  mass  behind  the  uterus  was  felt  in  the  pelvis,  and  tubercles 
of  various  sizes,  many  of  them  very  large,  were  felt  and  seen  all  over  the 
peritoneum.  A  median  incision  below  the  umbilicus  was  made,  and  a  hernia 
of  several  loops  of  intestine  was  found  through  the  opening  in  the  mesentery 
of  the  ileum.  The  hernia  was  reduced  and  the  opening  sutured.  A  cica- 
tricial stricture  of  the  ileum  was  found,  about  eight  inches  above  the  ileo- 
cecal valve.  Opposite  the  stricture,  and  for  a  considerable  space  on  the  other 
side,  the  mesentery  was  very  much  thickened  and  edematous,  so  it  was 


TUBERCULOSIS   OF   THE    PERITONEUM. — LUND.  195 

thought  that  resection  would  be  impossible,  and  therefore  a  lateral  anasto- 
mosis was  performed  around  the  stricture.  The  abdominal  wall  was  su- 
tured without  drainage.  Recovery  from  the  operation  was  uneventful. 
The  abdominal  symptoms  were  considerably,  but  not  completely,  relieved. 
Constipation,  as  might  be  expected  from  the  amount  of  adhesions,  re- 
quired constant  treatment.  The  patient,  six  months  after  the  operation, 
had,  however,  gained  about  ten  pounds  in  weight  and  looked  perfectly 
well. 

This  case  illustrates  the  fact  that  surgery  of  the  fibroplastic  form  of 
peritonitis  is  practically  limited  to  surgery  of  the  complications. 

Treatment. 

However  complicated  are  the  etiological  and  pathological  problems 
presented  by  this  multifold  disease,  the  chief  interest  to  us  as  surgeons  lies, 
after  all,  in  the  treatment.  The  progress  of  the  surgical  treatment  of  tuber- 
culous peritonitis  from  its  accidental  discovery,  through  its  empirical  stages, 
to  its  present  scientific  position,  is  one  of  the  most  interesting  bits  of  present- 
day  surgical  history.  In  following  the  story  w^e  shall  note  the  contributions 
of  surgery  not  only  to  the  treatment,  but  to  the  pathology  of  the  disease, 
and  mark  the  results  which  have  followed  the  extension  of  the  empirical 
incision  and  suture  of  the  peritoneal  cavity  to  the  rational  and  far  more 
effective  procedure  of  the  search  for  and  removal  of  the  primary  focus. 

The  surgical  treatment  of  tuberculous  peritonitis  dates  from  1862, 
when  that  pioneer  of  abdominal  surgery,  Sir  Spencer  Wells,  opened  a  case 
of  tuberculous  peritonitis  by  mistake  for  an  ovarian  cyst,  sewed  it  up  again, 
and  saw  his  patient  recover  and  remain  well.  Since  then  the  operation  of 
opening  the  abdomen  for  tuberculous  peritonitis  had  been  practised.  It 
may  be  noted,  in  passing,  that  this  was  one  of  the  encysted  cases  in  which 
the  collection  of  fluid  in  the  median  portion  of  the  abdomen  so  closely  re- 
sembles an  ovarian  tumor.  Konig,  however,  in  the  year  1884,  was  the  first 
formally  to  advise  the  operation,  and  in  1889  published  131  cases,  with,  he 
claimed,  about  70  per  cent,  of  cures.  Numerous  statistics  of  the  results  of 
surgical  treatment  have  since  been  published  with  from  60  to  80  per  cent, 
recoveries.  Among  the  authors  may  be  mentioned:  Konig,  1890;  Roessle, 
1893;  Margarucci,  1896;  Ebstein,  Krencki,  Thones,  IMickulicz,  Korte,  and 
others.  There  have  been  many  good  surgeons  and  careful  students  of  the 
disease,  such  as  Schede,  Czerny,  Pribram,  Kussmaul,  Shattuck,  Borchgre- 
vink,  and  Fenger,  who  have  laboriously  proved,  as  they  thought,  that  the 
results  of  operative  treatment  were  no  better,  or  slightly  worse,  than  in  cases 
treated  medically,  by  tapping,  tonics,  etc.  Through  all  these  controversies 
stood  out  the  fact  that  only  in  the  operated  cases  which  recovered  could  the 
diagnosis  be  absolutely  made;  involving  unreliability  in  the  medical  statistics 
of  recovery;  and  also  the  fact  that  since  the  operative  period,  the  prognosis 


196  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

of  tuberculous  peritonitis  had  improved  from  the  almost  absolutely  bad 
prognosis  of  the  seventies  to  the  60  to  85  per  cent.  "  cures"  of  the  nineties. 
This  was  partly  due  to  the  fact  that  in  the  preoperative  period  the  diagnosis 
was  not  made  before  the  disease  was  well  advanced,  and  the  light  cases 
which  recovered  gave  no  sign;  and  partly  to  several  other  reasons  connected 
with  the  operation.  This  skepticism  as  to  the  results  of  operative  treat- 
ment resulted  badly  in  many  ways.  Cases  were  kept  under  medical  treat- 
ment till  everything  had  been  tried  in  vain  before,  "weary  and  worn  and  sad," 
they  were  turned  over  to  the  surgeon  for  a  happy  despatch.  The  method 
tried  after  ever5^thing  else  has  failed  has  a  bad  chance,  and  forlorn  hopes 
will  probably  always  continue  to  be  forlorn.  The  surgeons,  however, 
sometimes  prevailed  by  the  argument,  if  this  is  a  good  thing,  let  us  try  it  in 
time  to  do  some  good  with  it.  The  fact  that  many  diagnoses  were  cleared 
up  was  not  the  least  of  the  benefits  conferred  by  surgery  in  these  doubtful 
conditions.  One  result  of  many  years  of  practice  in  opening  abdomens 
was  the  establishment  of  the  fact  that  the  ascitic  cases  were  favorable  to 
laparotomy,  while  the  fibroplastic  were  not.  This  result  does  not  seem 
strange  when  we  consider  that  we  were  trying  the  treatment  of  opening  the 
abdominal  cavity  in  cases  in  which  there  was  no  abdominal  Cavity  to  open, 
as  it  had  been  obliterated  by  adhesions,  and  that  in  our  attempt  to  find  a 
cavity  somewhere  the  danger  of  opening  the  intestines  and  causing  a  fecal 
fistula,  which  could  in  no  wise  be  induced  to  heal,  was  by  no  means  small. 
The  reason  why,  in  the  ascitic  form,  laparotomies  did  good,  nobody  knew. 
The  admission  of  air,  sunlight,  even  hostile  bacteria  at  the  operation  was 
given  the  credit.  Abdomens  used  to  be  held  open  for  some  time  while  given 
an  interior  sun-bath.  Irrigation  was  recommended — sponging,  not  spong- 
ing; manipulation,  avoidance  of  manipulation.  Drainage  and  non-drainage 
had  their  advocates,  but  it  soon  became  the  general  consensus  that  drainage 
was  to  be  avoided,  as  carrying  with  it  two  dangers,  namely,  those  of  secondary 
infection  and  fecal  fistula. 

A  theory  which  seemed  plausible  was  that  the  irritation  produced  by 
the  laparotomy,  together  with  the  loss  of  tension  due  to  the  evacuation  of 
the  fluid,  determined  a  flow  of  fresh,  anti-toxin-bearing  blood  to  the  peri- 
toneum, which  enabled  it  successfully  to  overcome  the  process.  In  a  con- 
dition so  chronic  in  character,  however,  this  seemed  hardly  satisfactory, 
even  in  certain  cases  in  which  repeated  laparotomy  was  followed  by  recovery. 
Bier's  congestion  theory  was  in  harmony  with  this  view,  however,  and  it 
had  many  adherents.  The  theory  at  this  time  which  came  nearest  to  the 
truth,  however,  was  that  the  adhesions  and  scar  tissue  produced  by  the 
operation  tended  to  a  localization,  and  consequent,  at  least  partial,  walling 
off  and  strangulation  of  the  process.  It  was  J.  B.  Murphy,  about  1904,  who 
observed,  and  was  one  of  the  first  to  appreciate,  the  importance  of  the  fact 


TUBERCULOSIS   OF   THE    PERITONEUM, — LUND.  197 

that  in  many  cases  of  tuberculous  peritonitis  in  women  the  Fallopian  tube 
was  thickened  and  presented  ulcerations  in  the  mucous  membrane,  and, 
what  was  more,  that  the  end  of  the  tube  was  open,  floating  free  in  the  serous 
exudate,  and  discharging  its  contents  into  the  abdominal  cavity.  He  calls 
attention  in  these  cases  to  the  futility  of  opening  the  cavity  and  evacuating 
the  fluid,  unless  at  the  same  time  the  diseased  tube  which  is  the  source  of 
infection  be  removed. 

Murphy  also  called  attention  to  the  fact  that  if  the  focus  of  supply  to 
the  peritoneum  is  a  mesenteric  gland  or  an  appendiceal  tuberculosis,  its 
removal  is  indicated,  as  is  the  removal,  under  similar  conditions,  of  a  tube. 
It  is  this  last  step  in  advance,  the  recognition  of  the  importance  of  the  re- 
moval at  operation  of  the  cause,  if  possible,  of  the  infective  process,  which 
has  given  us  a  rational  basis  for  our  treatment  by  laparotomy,  the  removal 
of  the  infective  process.  We  may  fairly  assume  that  the  cases  which 
were  laparotomized  previous  to  our  knowledge  of  this  principle  got  well, 
some  of  them  because  they  would  have  recovered  without  operation,  and 
some  because  the  closure  of  the  tube  or  the  encapsulation  of  some  other 
focus  by  the  resultant  inflammation  shut  off  the  source  of  supply. 

When  the  tuberculous  intestine  is  the  primary  focus,  if  the  adhesions 
be  not  too  extensive  or  the  area  too  great,  the  indication  is  to  resect.  A 
tuberculous  cecum  should  be  removed  v/hen  possible,  and  if  not  possible  on 
account  of  too  extensive  involvement  of  the  ascending  colon,  mesenteric 
glands,  etc.,  or  weakness  of  the  patient,  an  anastomosis  around  it  may  be 
made  between  the  ileum  and  the  transverse  colon. 

One  of  the  most  extensive  cases  which  I  ever  met,  in  a  thin,  feeble  young 
woman,  was  obviously  so  unfavorable  to  resection  that  I  did  the  ileocolic 
anastomosis.     She  did  beautifully,  grew  fat,  married,  and  had  a  baby. 

In  a  case  of  tuberculosis  of  the  ileum  with  stricture,  where  resection  was 
prevented  by  thickening,  edema  of  the  mesentery,  and  mesenteric  noditis, 
I  have  successfully  done  lateral  anastomosis  around  the  stricture.  (See  case 
of  Mrs.  L.)  Operations  for  the  removal  of  tuberculous  retrocecal  glands, 
in  some  cases  with  caseation  and  abscess  formation,  have,  in  my  hands,  been 
successful  and  curative. 

W.  J.  Mayo,  in  1905,  published  a  report  on  144  cases  and  called  attention 
to  his  improved  results  in  tuberculous  peritonitis,  ascitic  form,  since  removal 
of  the  infective  focus  was  practised.  Cases  were  cured  in  which  several  re- 
lapses and  reoperations  had  been  previously  done.  In  the  nodular  or  ul- 
cerative form  the  surgical  problem  becomes  entirely  different  and  much 
more  difficult  of  solution.  This,  more  often  than  the  previous  variety,  is 
due  to  enteric  and  glandular  infection.  Here,  as  in  the  adhesive  variety, 
the  greatest  care  must  be  taken  in  separating  adhesions,  lest  the  intestine 
be  opened  and  the  lamentable  complication  of  an  intractable  fecal  fistula 
result.     Cysts  and  caseous  masses,  if  opened,  should  not  be  drained,  but  dis- 


198  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

infected  and  closed.  In  these  two  classes  of  cases  it  may  be  doubtful  whether 
surgical  treatment  directed  at  the  disease  per  se  is  often  of  benefit. 

The  same  general  statements  apply  to  mixed  infections  either  with  one 
large  or  multiple  small  abscesses.  They  should  rarely  be  drained.  Mixed 
infections  of  tubal  or  appendiceal  origin  are,  of  course,  treated  by  removal 
of  the  tube  or  appendix,  the  utmost  care  being  taken  to  avoid  injury  to  the 
intestine.  If  injury,  either  to  the  rectum  or  other  intestine,  should  occur, 
it  must  be  closed  by  several  rows  of  sutures  and  wide  apposition.  Murphy 
has  successfully  sewn  the  uterus  against  an  opening  in  the  rectum,  so  as  to 
close  it. 

In  operating  for  the  exudative  form  of  tuberculous  peritonitis  where  the 
cause  is  not  known  it  is  well  to  do  as  Mayo  advises,  and  make  the  incision 
in  the  median  line  in  women,  and  in  men  over  the  appendix,  so  as 
to  be  ready  in  either  case  for  attack  upon  the  most  probable  primary 
focus.  It  has  been  my  fortune  in  men  and  boys  to  meet  with  many  cases 
in  which  the  primary  focus  could  not  be  found.  In  these  cases  the  appen- 
dix has  been  removed,  but  has  been  found  to  show  no  more  involvement  than 
the  remainder  of  the  peritoneal  cavity.  Here  we  have  been  accustomed  to 
evacuate  the  fluid,  wash  out  with  salt  solution,  suture  without  drainage, 
and,  as  soon  as  possible,  get  the  patient  up  and  into  the  country  under  the 
best  possible  hygienic  conditions. 

BIBLIOGRAPHY. 

Murphy,  John  B.:  "Tuberculosis  of  the  Female  Genitalia  and  Peritoneum,"  Amer. 
Jour.  Obstet.,  vol.  xlix,  1904. 

Mayo,  W.  J.:  "Surgical  Tuberculosis  in  the  Abdominal  Cavity,  with  Special  Reference 
to  Tuberculous  Peritonitis,"  Jour.  Amer.  Med.  Assoc,  vol.  xliv,  1905. 

Bottomley,  John  T.:  "A  Consideration  of  Twenty-eight  Cases  of  Tuberculous  Peri- 
tonitis at  The  Boston  City  Hospital,  with  Particular  Reference  to  the  Results 
of  Operative  Treatment,"  Med.  and  Surg.  Reports  of  the  Boston  City  Hospital, 
eleventh  series,  1900. 

Hertzler,  A.  E.:  "Hyperemia  in  the  Treatment  of  Tuberculosis  of  the  Peritoneum," 
Surg.,  Gynec,  and  Obst.,  Chicago,  1907,  v,  652. 

Syms,  P.:   "Peritoneal  Tuberculosis,"  Am.  Surg.,  Philadelphia,  1907,  xlvi,  95-110. 

Guthrie,  T.:  "The  Treatment  of  Tuberculous  Peritonitis,"  Practitioner,  London,  1906, 
Ixxvi,  642-653. 

Broca:   "Uber  die  Therapie  der  Bauchtuberkulose  im  Kindesalter,"  Wien.  med.  Presse, 

1906,  clvii,  1,505. 

Neurath,  R. :  "Die  Behandlung  der  Bauchfelltuberkulose  im  Kindesalter,"  Wien.  med. 
Presse,  1906,  xlvii,  565. 

Biidlinger,  K.:  "Uber  die  chirurgische  Behandlung  der  Bauchfelltuberkulose,"  Wien. 
med.  Presse,  1906,  xlvii,  397,  464. 

Johnson,  R.:  "Unsuspected  Tuberculous  Peritonitis,"  Practitioner,  London,  1906, 
Ixxvi,  332. 

Gelpke:  " Beobachtungen  uber  tuberkulose  Peritonitis  an  Hand  von  64  operatii,  teils 
intern  behandelten  Fallen,"  Deut.  Zeitschr.  f.  Chir.,  Leipzig,  1906,  Ixxxiv,  512. 

Schmid,  H.:  "  Dauerresultate  bei  operativer  und  konservativer  Behandlung  der  Peri- 
tonitis tuberculosa  im  Kindesalter,"  Jahrb.  f.  Kinderh.,  Berlin,  1907,  Ixvi,  399. 

D6v6,  F.:   "La  pseudotuberkulose  hydatique  du  pcritoine,"  Arch,  de  m6d.  exp.,  Paris, 

1907,  xix,  347. 

Berard  (L.)  and  M.  Patel:  "De  la  pdritonite  g^n^ralis^e  par  perforation  au  cours  de 
I'enterite  tuberculeuse,"  Rev.  de  chir.,  Paris,  1906,  xxxiii,  899. 


SECTION  III. 
Surgery  and  Orthopedics  (Continued), 


FIFTH  DAY. 

Friday,  October  2,  1908. 

HYGIENIC  TREATMENT   OF   SURGICAL   TUBERCULOSIS.     TUBER- 
CULOSIS OF  MUSCLES,  FASCL^,  AND  TENDONS;    GALL- 
BLADDER, PANCREAS,  STOMACH,  AND  LIVER. 


The  Section  was  called  to  order  by  the  President,  Dr.  Charles  H.  Mayo,  at 
half-past  nine  o'clock. 


SURGICAL  BEARINGS  OF  TUBERCULIN. 
By  R.  W.  Philip,  M.  A.,  M.  D.,  F.  R.  C.  P., 

Hon.  Phjrsician  to  the  Royal  Infirmary  and  to  the  Royal  Victoria  Hospital  for  Consumption, 

Edinburgh. 


The  frequency  of  tuberculous  lesions  in  surgical  wards  is  well  known. 
Visit  a  surgical  clinic  an^'where  and  any  time,  one  of  the  striking  features  is 
the  number  of  patients  suffering  from  one  or  other  manifestation  of  tuber- 
culosis. The  tuberculous  lesions  are  of  different  grades.  Many  are,  for- 
tunately, at  a  stage  when  the  injury  is  localized  and  comparatively  slight. 
In  others  the  disturbance  has  been  allowed  to  advance  until  the  extent  of 
involvement  is  great  and  its  limits  are  not  readily  defined.  In  many  there 
is  associated  constitutional  prejudice.  Of  the  group  of  advanced  cases, 
it  is  a  truism  to  affirm — but  the  truism  is  of  great  significance — that,  at  one 
time,  the  lesions  were  comparatively  slight  and  local. 

Prolonged  experience  in  the  use  of  tuberculin  for  a  great  variety  of  tuber- 
culous conditions  emboldens  me,  physician  though  I  be,  to  accept  the  presi- 
dent's invitation  to  take  part  in  the  work  of  the  surgical  section  of  the  con- 

199 


200  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

gress.  Tuberculin  plays  a  double  role  in  relation  to  so-called  surgical  tuber- 
culosis. Its  influence  is  conspicuously  conservative.  This  is  effected  by  its" 
remarkable  power  of  limitation  of  tuberculous  disease. 

In  this  sense  it  may,  on  the  one  hand,  anticipate  surgical  interference,  and 
even  render  such  interference  unnecessary.  Or,  on  the  other  hand,  it  may 
prepare  the  way  for  surgical  interference  by  defining  and  limiting  the  area 
involved.  Thus,  for  example,  in  the  case  of  glandular  tuberculosis,  where 
one  or  several  glands  are  alone  enlarged,  the  timely  use  of  tuberculin,  with 
careful  dosage  at  suitable  intervals,  may  lead  to  resolution  of  the  process 
and  prevent  the  need  for  surgical  interference.  I  have  had  such  experience 
again  and  again.  On  the  other  hand,  there  are  cases  where  many  glands 
are  simultaneously  involved  and  infection  extends  deeply,  and  the  clinical 
picture  produces  the  uncomfortable  impression  that,  if  surgical  interference 
be  undertaken,  either  the  surgeon  will  have  to  stop  half-way  and  admit 
failure,  or  the  knife  will  have  to  pass  deeply  and  undertake  dissections  the 
limits  of  which  are  dubious.  I  have  in  my  mind  cases  where  not  several 
glands  only  were  involved,  but  where  so  many  were  involved  as  to  be  prac- 
tically uncountable,  and  where  several  had  already  been  treated  surgically 
with  only  partial  success,  in  which  brilliant  results  were  obtained  by  the  use 
of  tuberculin. 

I  recall  one  case  in  particular  where  the  number  of  glands  was  uncount- 
able, and  where  sinuses,  following,  in  part,  surgical  interference,  and,  in 
part,  spontaneous  rupture,  formed  an  almost  continuous  chain  around  the 
front  of  the  neck,  with  ugly  discoloration  of  the  adjacent  skin  surfaces. 
Within  six  months  from  the  commencement  of  treatment  by  tuberculin 
all  the  sinuses  healed,  the  glandular  enlargement  practically  disappeared, 
and,  save  for  a  few  scars,  the  skin  had  assumed  its  normal  aspect.  Con- 
trariwise, I  recall  cases  where  tuberculin  was  either  excluded  from  the  first, 
or  dropped  after  its  use  had  been  undertaken,  and  where,  through  haste  to 
obtain  result,  operation  after  operation  was  performed,  only  to  be  followed 
by  disappointment. 

In  many  such  difficult  cases  the  most  favorable  result  is  obtained  by  a 
judicious  combination  of  tuberculin  treatment  with  surgical  interference. 
In  presence  of  enlarged  glands  I  recommend  that  treatment  be  commenced 
with  tuberculin  in  minute  doses  at  carefully  regulated  intervals.  I  shall 
refer  to  the  details  of  procedure  presentl3\  In  some  instances  the  employ- 
ment of  tuberculin  may  alone  suffice  to  cause  resolution.  Even  when  many 
glands  are  involved,  tuberculin  will  lead  to  resolution  of  the  majority,  more 
especially  those  located  at  the  greatest  distance.  If  suppuration  be  deter- 
mined in  one  or  several  glands,  surgical  interference  for  the  relief  of  this  may 
be  undertaken,  the  use  of  tuberculin  being  maintained.  It  is  remarkable  how 
rapidly  evacuation  of  pus  is  effected  in  such  circumstances,  and  a  healthy 


SURGICAL   BEARINGS   OF   TUBERCULIN. — PHILIP.  201 

cicatrization  follows.  Tuberculin  is  no  less  serviceable  in  relation  to  local- 
ized tuberculosis  of  bones  and  joints.  In  all  cases,  but  especially  in  the 
osseous  and  articular  group,  advantage  seems  to  be  obtained  by  the  intro- 
duction of  tuberculin  directly  witliin  the  affected  area. 

There  remains  for  consideration  a  large  group  of  difficult  conditions  in 
which  frequently  tulDerculin  may  replace  surgical  interference  entirely. 
This  group  includes  two  classes : 

(a)  Certain  obscure  cases  where  localization  of  lesion  is  not  exact,  or 
where  operative  procedure  is  doubtful  or  has  been  fruitless. 

I  might  cite  several  examples.  For  the  present,  it  may  suffice  to  record 
one  striking  case  which  has  recently  been  under  my  observation.  The 
patient,  a  young  lady  of  thirty,  came  to  me  three  j^ears  ago,  on  account  of  a 
distressing  discharge  of  pus  per  rectum,  amounting  to  some  eight  to  ten 
ounces  daily.  The  discharge  had  continued  for  almost  four  years.  During 
that  time  she  had  had  the  best  surgical  advice.  Two  surgical  operations 
had  been  undertaken  by  way  of  the  rectum.  More  recently,  a  laparotomy 
had  been  performed  with  a  view  to  clearing  up  the  diagnosis  and  effecting 
a  cure.  In  spite  of  such  heroic  measures,  carefully  carried  out,  with  the 
addition  of  long-continued  rest  on  open-air  lines,  the  discharge,  when  I  first 
saw  her,  was,  she  informed  me,  as  great  as  ever.  Examination  showed  the 
traces  of  the  surgical  interference,  not  merely  in  the  superficial  scar,  but, 
unfortunately,  also  in  a  cicatricial  narrowing  of  the  rectum,  which  was  the 
cause  of  much  mechanical  difficulty  in  defecation.  High  up,  as  far  as  the 
finger  could  reach,  there  was  felt  to  be  a  considerable  boggy  area  in  relation 
to  the  posterior,  or  sacral,  aspect  of  the  rectum.  Pressure  over  this  area 
caused  pain  and  bleeding  and  the  discharge  of  pus.  It  was  to  this  area  that 
the  rectal  operations  had  been  especially  directed. 

Concluding  that  the  lesion  was  of  tuberculous  nature,  and  having  regard 
to  the  complete  lack  of  success  of  repeated  surgical  interference,  I  proposed 
treatment  by  tuberculin.  The  result  was  remarkable.  After  the  first  two 
or  three  injections  improvement  was  noted  by  the  patient.  Within  three 
months  the  discharge  of  pus,  which  had  lasted  almost  four  years,  was  greatly 
reduced,  and,  at  the  end  of  six  months,  had  entirely  disappeared.  The 
patient's  general  condition  improved  simultaneously.  For  two  years  she 
has  been  free  from  any  trace  of  discharge,  and,  apart  from  the  distressing 
consequences  of  the  operative  interference  (rectal  cicatrization  and  hernial 
bulging  of  the  abdominal  wall),  has  been  well. 

(6)  Tuberculin  may  similarly  replace  surgical  interference  in  a  number  of 
admittedly  inoperable  cases.  Here  I  content  myself  with  reference  to  ex- 
tensive genito-urinary  tuberculosis,  with  involvement  of  kidneys,  bladder, 
and  presumably  other  parts  where  radical  surgical  interference  would  be 
impossible.    In  such  cases  the  effect  of  careful  and  continued  use  of  tuber- 


202  SIXTH    INTERNATIONAL   CONGRESS    ON   TUBERCULOSIS. 

culin  is  very  remarkable.  I  have  had  a  large  series  of  such  cases,  and  the 
net  result  has  been  satisfactory.  In  every  instance  so  far  improvement  has 
been  achieved,  and  in  many  the  improvement  has  am^ounted  to  cure.  Thus, 
I  have  had  cases  where  life  was  made  miserable  day  and  night  by  frequency 
of  micturition,  vesical  relief  being  called  for  every  hour  or  more  frequently, 
and  where,  after  a  dozen  or  two  injections,  micturition  was  restored  to  nor- 
mal order.  In  other  cases  large  discharge  of  pus  has  been  reduced  to  a 
minimum  or  has  been  made  to  disappear,  and  likewise  tubercle  bacilh  have 
disappeared  or  been  greatly  reduced. 

In  such  cases,  even  if  absolute  cure  be  not  effected,  it  is  of  vast  significance 
to  the  patient  that  at  least  the  more  urgent  symptoms,  which  make  life 
hardly  worth  Hving,  should  be  removed.  The  relief  reported  by  many 
patients  is  most  gratifying. 

In  other  affections,  where  the  leading  symptom  is  traceable  to  tubercu- 
lous involvement,  c.  g.,  the  distressing  dysphagia  which  accompanies  tuber- 
culous involvement  of  the  epiglottis,  I  have  confidence  in  recommending  the 
use  of  tuberculin  as  likely  to  be  followed  by  the  reduction  or  disappearance 
of  the  symptom,  even  if  completer  cure  be  not  always  obtained. 

Of  the  various  tuberculins,  I  have  used  several,  including  more  espe- 
cially Koch's  Original  Tuberculin,  Koch's  TR,  and,  more  recently,  Beraneck's 
tuberculin.  The  last  named  seems  to  me  worthy  of  special  consideration. 
Each  case  requires  to  be  judged  'per  se,  but  the  general  plan  of  treatment  is 
uniform.  It  has  been  my  rule  to  commence  with  minute  doses — thus,  of 
Koch's  Original  Tuberculin,  0.0001  gram,  of  TR  tuberculin  •g^Vo'  ^o  ytot 
milligram,  and  of  Beraneck's  tuberculin  0.1  c.c.  of  a  1  :  100,000  solution. 
Dilutions  are  made  with  normal  saline  solution.  Injection  is  repeated  at 
intervals  of  from  three  to  fourteen  days,  according  to  the  nature  of  the  case 
and  the  effect  produced.  The  effect  is  gaged  by  careful  record  of  tempera- 
ture, pulse,  general  condition  of  patient,  and  local  manifestations.  Al- 
though my  observations  have  been  controlled  in  many  instances  by  daily 
estimation  of  the  opsonic  index,  I  do  not  think  this  is  necessary.  I  am  satis- 
fied that  the  amount  and  frequency  of  dosage  may  be  regulated  sufficiently — 
indeed,  regulated  fully  as  well — ^by  clinical  evidence. 

I\Iy  practice  has  been  to  commence  with  the  smallest  dose  that  seemed 
likely  to  be  effective,  and  thereafter  to  proceed  with  treatment  very  grad- 
ually at  sufficiently  wide  intervals.  It  is  commonly  desirable  to  repeat  the 
same  dose  on  more  than  one  successive  occasion,  so  as  to  be  sure  that  no 
reaction  has  been  missed.  Thereafter  the  dose  may  be  progressively  in- 
creased in  similar  fashion  until  a  considerably  larger  dose  is  attained. 

It  is  especially  important  to  commence  with  small  doses  when  the  surgi- 
cal lesion  is  internal,  or,  if  external,  is  associated  with  visceral  tuberculosis, 
e.  g.,  pulmonary,  or  when  although  no  internal  lesion  is  determinable,  there 
is  much  constitutional  prejudice. 


SURGICAL   BEARINGS   OF   TUBERCULIN. — PHILIP.  203 

When,  contrariwise,  the  surgical  lesion  seems  entirely  external,  it  is  per- 
missible to  commence  with  larger  doses,  the  same  precaution  being  followed 
in  respect  of  clinical  observation  and  progressive  graduation  of  dosage. 

Sometimes,  when  the  disease  is  certainly  external,  direct  introduction 
of  tuberculin  into  the  diseased  area  is  to  be  recommended.  In  such  cases 
also  the  stronger  solutions  may  be  used.  Thus,  of  Beraneck's  tuberculin,  I 
have  commenced  with  y^  c.c.  of  1 :  100.  After  injection,  the  affected  area 
must  be  carefully  observed.  If  there  is  trace  of  local  reaction,  no  further 
injection  is  made  until  this  has  disappeared.  If,  as  commonly  happens, 
all  trace  of  reaction  has  disappeared,  at  the  end  of  a  week  the  same  dose  is 
repeated.  If  no  local  reaction  has  taken  place  or  the  reaction  has  been 
slight,  the  dose  is  increased  yV  c-c,  and  so  on  gradually,  a  pause  being  always 
made  in  presence  of  definite  reaction  until  all  trace  of  reaction  has  dis- 
appeared. 

La  Tuberculina  en  los  Cases  Quirurgicos. — (Philip.) 
La  tuberculina  un  agente  valioso  en  la  cirugia  conservativa. 
Ejemplos. — La  tubercuhna  puede  reemplazar  las  interposiciones  quirur- 
gicas.  (a)  En  ciertos  casos  oscuros,  cuando  el  diagnostico  principal  no  es 
exacto,  6  cuando  los  procedimientos  quirurgicos  son  dudosos  6  no  han 
tenido  exito.  (6)  En  un  niimero  de  los  casos  inoperables  v.  g.  en  una  extusa 
afeccion  tuberculosa  de  los  organos  genito-urinarios,  en  la  cual  el  trata- 
miento  operativo  radical  es  imposible. 


Aspects  Chirurgicaux  de  la  Tuberculine. — (Philip.) 
La  tubercuhne  est  un  agent  important  de  la  chirurgie  conservative. 
Exemples. — La  tuberculine  peut  remplacer  I'intervention  du  chirurgien: 

(a)  dans  certains  cas  obscurs,.  ou  le  diagnostic  topique  n'est  pas  exact,  ou 
quand  le  succes  de  I'operation  est  douteux,  ou  que  I'operation  n'a  pas  reussi. 

(b)  Dans  nombre  de  cas  non  operables,  par  exemple,  la  tuberculose  genito- 
urinaire  etendue  dans  laquelle  une  intervention  chirurgicale  radicale  peut 
etre  impossible. 

Uber  die  Stellung  des  Tuberculins  in  der  Chirurgie. — (Philip.) 
Das  Tuberculin  ist  ein  werthvolles  Mittel  in  der  conservativcn  Chirurgie. 
Beispiele. — Das  Tuberculin  kann  einen  chirurgischen  Eingriff  ersetzen: 
(a)  In  gewissen  Fallen,  in  denen  eine  topische  Diagnose  nicht  mit  Sicher- 
heit  gestellt  werden  kann,  oder  wenn  das  Resultat  des  operativen  Ein- 
griffes  entweder  zweifelhaft  oder  fruchtlos  war.  (h)  In  einer  Anzahl  nicht 
operirbarer  Falle,  wie  z.  B.  bei  ausgedehnter  Tuberculose  der  Harn-  und 
Geschlechtsorgane,  in  denen  ein  radicales  chirurgisches  Eingreifen  eventuell 
unmogUch  ist. 


TUBERCULOSIS  OF  BONES  AND  JOINTS. 

By  Edward  H.  Bradford,  M.D., 

Boston. 


In  the  study  of  the  control  of  tuberculosis  attention  has  been  turned 
more  particularly  to  that  form  of  tuberculous  disease  which  attacks  the  or- 
gans of  respiration,  for  the  reason  that  pulmonary  tuberculosis  is  regarded 
as  one  of  the  chief  sources  of  contagion,  and  also  popularly  as  the  type  of  the 
white  plague.  The  suppression,  however,  of  other  forms  of  tuberculosis  is 
of  equal  importance. 

The  present  paper  will  attempt  to  call  attention  to  one  of  the  most  com- 
mon forms  of  tuberculosis  which  comes  under  the  attention  of  the  surgeon, 
viz.,  tuberculosis  of  the  bones  and  joints. 

Tuberculous  periostitis,  tuberculous  involvement  of  the  glands,  tuber- 
culosis of  the  kidney,  of  the  testis  and  the  prostate,  of  the  mesenteric  glands 
and  larynx,  are  all  classed  as  surgical  tuberculosis.  But  the  surgical  treat- 
ment varies  with  the  locality  invaded,  and  needs  special  surgical  consider- 
ation as  to  the  question  of  surgical  interference.  All  treatment,  however, 
must  be  subject  to  the  treatment  of  the  patient's  condition,  which  is  at 
present  regarded  as  the  development  of  an  immunity  from  the  tuberculous 
infection. 

This  is  equally  true  when  the  tissues  attacked  are  or  are  not  accessible 
to  surgical  interference.  When  the  tissues  invaded  are  placed  under  suitable 
conditions,  healing  takes  place  and  the  affected  tissues  become  cicatrized. 
The  detritus  of  diseased  tissues  is  either  thrown  off  or  encapsulated. 

In  tissues  within  the  reach  of  surgical  interference  the  surgeon  is  to  decide 
whether  the  healing  process  can  be  hastened  by  removing  the  affected  tissues 
or  the  detritus.  This  depends  upon  both  the  nature  of  the  tissues  and  the 
anatomical  situation  of  the  parts  affected. 

These  considerations  are  particularly  important  in  bone  tuberculosis  and 
tuberculosis  of  the  joints,  for  the  reason  that  bone  is  a  tissue  that  cicatrizes 
slowly  and  the  articulations  are  especially  exposed  to  bruising  and  trauma, 
which  are  unfavorable  to  the  healing  of  tuberculous  tissues. 

The  treatment  of  surgical  tuberculosis  consists,  therefore,  in  operative 
interference  and  the  promotion  of  healing  by  protecting  the  tissues,  in 

204 


TUBERCULOSIS    OF   BONES    AND   JOINTS. BRADFORD.  205 

addition  to  furnishing  such  measures  as  are  useful  in  combating  tuberculosis 
in  general. 

General  Measures. 

Of  the  measures  wliich  are  of  importance  for  the  general  treatment  of 
tuberculosis,  fresh  air  is  of  as  much  value  in  bone  and  joint  tuberculosis  as 
in  any  other  form  of  tuberculous  infection.  Although  this  fact  has  been 
surmised  for  a  long  time,  it  is  only  within  a  comparatively  short  time  that 
the  important  agency  of  fresh  air  as  a  tonic  has  begun  to  be  realized.  The 
opposition  to  drafts,  to  cold  air,  the  fear  of  "catching  cold,"  which  is  an 
obstacle  to  be  overcome  in  the  treatment  of  pulmonary  phthisis,  is  even 
greater  in  many  instances  in  bone  and  joint  tuberculosis,  which  more  fre- 
quently attacks  young  and  delicate  children,  guarded  as  they  usually  are 
with  the  solicitude  and  tradition  of  domestic  nursing. 

Even  physicians  who  have  learned  to  regard  fresh  air  as  beneficial  in 
phthisis  have  frequently  not  thought  that  in  bone  tuberculosis,  where  the 
affected  tissues  are  not  accessible  to  fresh  air,  the  same  benefit  can  be  ob- 
tained. There  is  a  dread  of  added  complication  induced  by  the  chilling  of 
the  surface  temperature  which  has  deterred  attempts  at  what  is  regarded 
as  exposure. 

But  accumulated  experience,  from  many  regions  and  many  climates,  is 
convincing  as  to  the  gain  to  be  obtained  from  the  tonic  of  pure  air,  no  less 
in  bone  tuberculosis  than  in  other  varieties.  It  is  unnecessary  to  speculate 
here  as  to  the  mode  of  action  of  this  tonic,  but  it  is  desirable  to  determine  in 
what  cases  it  is  especially  beneficial. 

The  illustrations  of  benefit  from  fresh-air  treatment  in  tuberculous 
children  have  been  so  numerous  that  it  might  be  considered  superfluous  to 
cite  further  illustrations,  but  the  experience  gained  from  the  open-air  treat- 
ment at  the  Wellesley  Country  Convalescent  Home  of  the  Boston  Children's 
Hospital  is  in  some  respects  unusual,  as  the  cases  were  not  those  taken 
directly  from  the  slums,  but  from  the  wards  of  a  well-appointed  city  hospital, 
without  unusual  provision  for  fresh  air,  though  with  the  usual  ventilation  of 
a  hospital  built  twenty- five  years  ago. 

Owing  to  delay  in  constructing  the  fresh-air  shack  added  to  the  facilities 
of  the  Country  Home,  which  was  to  have  been  opened  in  the  early  autumn, 
patients  were  not  admitted  until  the  early  winter,  and  children  suffering 
from  hip  disease  and  diseases  of  the  spine  were  first  placed  under  continued 
fresh-air  treatment,  not  in  the  milder  weather,  but  in  winter,  when  the 
thermometer  ranged  from  zero  to  ten  and  twelve  degrees  below.  The  im- 
provement in  these  cases  was  immediate  and  surprisingly  great — in  appetite, 
general  condition,  weight,  and  hemoglobin  percentage.  This  was  true  not 
only  of  children  capable  of  activity,  but  also  of  children  who  were  confined 


206  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

to  recumbent  frames  and  moved  about  on  movable  stretchers.  It  was 
found,  however,  that  the  cases  with  increasing  and  undrained  abscesses  did 
not  gain  as  rapidly  as  those  with  sinuses.  In  certain  cases  no  gain  followed 
fresh-air  treatment,  and,  although  it  is  difficult  to  generalize  absolutely,  it 
appeared  that  those  suffering  from  the  acuter  forms  of  surgical  intervention 
were  less  benefited  by  fresh-air  treatment  than  those  in  a  more  chronic 
condition. 

It  appeared  in  many  instances  that  the  benefit  from  the  fresh  air  was 
largel}^  an  improvement  of  the  metabolism  from  the  general  tonic,  which  was 
as  marked,  if  not  more  so,  in  the  cold  air  of  a  severe  winter  as  in  the  summer. 
The  dry,  clear,  sun-lit  cold  apparently  served  as  a  stimulant,  provided  the 
children  were  warmly  clothed  and  were  able  to  respond  to  the  stimulus. 

It  is  not  yet  determined  that  sea  air  has  any  especial  advantage  over 
mountain  air,  or  even  over  fresh  air.  It  is  probable  that  this  question  in 
reality  is  the  practical  one  for  each  locality  in  favor  of  that  region  which  is 
accessible  and  which  furnishes  the  most  equable  temperature.  What  is 
needed  is  the  maximum  of  fresh  air  with  the  least  sudden  variation  of  heat 
and  cold,  dryness  and  humidity. 

In  advanced  cases  of  phthisis  the  husbanding  of  the  patient's  strength  is 
of  the  greatest  importance,  and  activity  which  brings  an  added  strain  upon 
the  lungs  is  to  be  avoided.  The  condition  is  different  in  bone  and  even  joint 
tuberculosis.  Increased  circulation  does  not  of  itself  devitalize  or  injure  a 
local  tuberculous  process  in  bone,  and  activity,  when  it  can  be  made  possible 
without  irritation  to  the  local  bone  lesion,  is  not  only  not  injurious,  but  even 
beneficial,  especially  in  children  where  activity  is  an  essential  to  normal  life. 

It  has  been  suggested  that  increased  metabolism  may  increase  the  danger 
of  the  generalization  of  the  tuberculous  process,  where  the  immunity  has  not 
been  yet  established ;  for  this  reason  it  is  manifestly  not  desirable  to  encour- 
age activity  during  the  stage  of  elevated  temperature  or  rapid  pulse,  which 
may  be  regarded  as  a  period  when  the  patient  is  in  the  struggle  of  infection; 
but  this  stage  is  brief,  and  may  be  absent  in  bone  and  joint  tuberculosis. 

Activity,  however,  may  be  regarded,  like  massage  and  hydrotherapeu- 
tics,  as  a  method  of  promoting  a  more  normal  metabolism,  and  under  gui- 
dance it  may  be  made  the  most  beneficial  of  all  methods  for  this  purpose. 

Surgical  Treatment. 
The  present  surgical  treatment  of  bone  tuberculosis  may  be  regarded  as 
having  developed  from  that  of  the  past  to  the  extent  of  retaining  the  essence 
of  that  which  was  useful  in  past  surgery,  with  the  addition  of  the  teaching  of 
more  recent  experience.  The  fixation  of  the  joints  is  important  at  a  certain 
stage,  namely,  the  stage  of  acute  invasion;  but  it  is  not  needed  at  all  stages, 
and  greater  freedom  should  be  allowed  in  the  convalescent  stages,  where  the 


TUBERCULOSIS   OF    BONES    AND   JOINTS. — BRADFORD.  207 

exercise  and  hyperemia  of  slight  motion  are  found  to  be  of  advantage  in 
restoring  function  to  the  cicatrized  periarticular  tissues.  Counterirritants, 
which  were  considered  of  so  great  value  by  the  surgeons  of  the  past  genera- 
tion, now  find  their  place  in  the  h^^peremia  treatment  which  is  of  benefit  in 
reducing  the  sluggish  congestion  of  swollen  periarticular  tissue.  Operative 
interference  is  of  proved  value  in  advanced  cases  with  marked  necrosis,  and 
the  value  of  perfected  mechanisms  in  the  prevention  of  deformity  has  been 
abundantly  proved. 

It  is  evident  that  in  the  surgical  treatment  of  bone  tuberculosis  the 
indications  for  surgical  interference  will  vary  with  the  locality  attacked. 
The  treatment  of  tuberculosis  of  the  vertebral  bodies  will  necessarily  be  dif- 
ferent from  that  of  tuberculosis  of  the  sternum.  Certain  general  principles, 
however,  must  be  borne  in  mind  by  surgeons.  Although  it  was  at  one  time 
thought  that  all  tuberculous  foci  demanded  surgical  interference,  and  all 
bone  tissues  invaded  by  the  tuberculosis  process  needed  extirpation,  at 
present  the  tendency  of  surgical  belief  is  toward  a  more  conservative  pohcy. 
Tuberculous  invasion  attacks  the  spongy  portion  of  the  bone,  and  by  prefer- 
ence that  portion  of  the  spongy  portion  where  the  development  of  new  cells 
is  likely  to  take  place,  namely,  the  epiphyses  or  the  juxta-epiphyseal  region. 
Hard,  dense  bone  is  ordinarily  resistant  to  the  tuberculous  invasion.  The 
spreading  of  tuberculous  invasion  in  bone  is  probably  not  rapid,  and  is  usually 
accompanied  by  the  development  of  cicatricial  bone  tissue  surrounding  the 
focus  or  the  portion  invaded.  Bone  tuberculosis  may  be  regarded  as  a  con- 
flict betw^een  the  invading  tuberculous  processes  and  the  resistant  cicatrizing 
processes,  wdth  the  chances  in  favor  of  the  resisting  tissue  if  proper  conditions 
are  furnished.  Although  this  is  true  of  tuberculous  invasion  of  all  tissue,  it 
is  especially  so  in  bone  tuberculosis,  owing  to  the  firm  and  resisting  texture 
of  certain  portions  of  the  bone  tissue.  The  circumscribed  cicatricial  ostitis 
in  the  majority  of  cases  gains  and  establishes  a  cure,  either  by  encysting  the 
tuberculous  mass  or  by  the  gradual  substitution  of  dense  cicatricial  bone  in 
the  place  of  the  spongy  bone  tissue  diseased  by  the  tuberculous  invasion. 
The  surgical  treatment  should  therefore  be  directed  toward  aiding  this 
natural  tendency  to  cicatrization  rather  than  interrupting  it.  Formerly 
tuberculous  tissue  v/as  regarded  as  semi-malignant,  and  therefore  demanding 
excision  to  prevent  the  danger  of  a  generalized  process.  At  present  it  may 
be  said  that  it  is  not  desirable  to  destroy  the  encircUng  cicatrizing  hard 
bone  process  unless  it  is  necessary  to  free  a  mass  of  detritus  or  necrotic 
bone  too  great  to  allow  reestablishment  of  normal  bone. 

The  surgeon  should  bear  in  mind,  therefore,  that  as  far  as  possible  it  is 
necessary  to  avoid  injury  to  cicatricial  bone  tissue.  Injury  to  this  tissue  not 
only  weakens  the  protection  against  a  generalization  of  the  process,  but,  in 
the  resulting  bruised  tissue,  furnishes  a  soil  for  the  local  spread  of  the  tuber- 


208  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

culous  ostitis.  It  is  impossible  for  the  surgeon  by  any  means  of  intervention, 
by  the  use  of  the  curet  or  the  chisel,  to  avoid  bruising  the  sounder  bone  in 
the  vicinity  of  the  diseased  tissue.  Unless  a  patient  has  already  established 
an  immunity,  such  bruising  of  the  young  cell  growi:h  furnishes  an  excellent 
medium  for  the  development  of  tuberculous  tissue,  and  instead  of  a  brilliant 
result  following  the  surgical  intervention,  in  too  many  instances  the  ultimate 
condition  of  the  patient  is  not  satisfactory.  Direct  surgical  intervention 
must  not,  therefore,  be  regarded  as  an  essential  of  treatment,  but  as  a 
measure  to  be  resorted  to  in  the  more  severe  cases.  A  dread,  however,  of 
surgical  intervention  in  bone  tuberculosis  is  to  be  rejected  as  irrational. 
Bone  heals  as  completely  as  other  tissues,  though  somewhat  more  slowly. 

In  the  early  preaseptic  days  surgeons  regarded  operative  intervention 
upon  tuberculous  bone  with  hesitation;  rest  and  counterirritation  were  the 
important  remedies.  Later,  bone  tuberculosis  was  classed  as  an  evil  to  be 
eradicated  thoroughly.  At  present  a  middle  course  seems  more  wise.  A 
combination  of  the  constitutional  bone  protection  and  operative  methods 
may  be  said  to  constitute  the  modern  treatment  of  bone  tuberculosis. 

It  is  of  prime  importance  that  the  surgeon  should  provide  that  all  bone 
tissue  attacked  by  tuberculosis  should  be  protected  from  bruises,  jars,  or 
repeated  trauma.  The  importance  of  this  is  seen  in  the  fact  that  bone 
tuberculosis  in  the  upper  extremity  is  less  destructive  and  more  easily 
arrested  than  bone  tuberculosis  in  the  larger  joints  of  the  lower  extremity 
or  in  the  spinal  column.  In  extensive  bone  tuberculosis  the  periarticular 
tissues  of  the  capsules  of  the  synovial  membrane  usually  become  involved, 
and  at  times  all  motion  of  the  joint  is  painful.  When,  however,  cicatrization 
and  cure  have  been  nearly  established,  some  motion  at  the  joint  is  not  only 
harmless,  but  may  be  beneficial. 

Another  factor  which  it  is  necessary  for  the  surgeon  to  bear  in  mind  is 
the  danger  of  mixed  infection.  It  has  been  shown  that  in  the  majority  of 
fatal  cases  of  joint  tuberculosis  death  does  not  result  from  tuberculous  gen- 
eralization so  much  as  from  a  septicemia  due  to  specific  infection  of  the 
tuberculous  bone.  The  surgeon  should  as  far  as  possible  avoid  all  chance  of 
the  invasion  of  the  pus-forming  germs,  and  for  that  reason  active  surgical 
intervention  demands  the  most  careful  aseptic  precautions  both  during 
operation  and  in  long  subsequent  after-treatment. 

A  factor  of  importance  in  the  treatment  of  joint  tuberculosis  consists  in 
the  prevention  of  deformities  which  necessarily  follow  the  natural  cure  of 
joint  tuberculosis  and  caries  of  the  spine.  The  surgeon,  therefore,  has  to 
consider:  the  question  of  the  eradication  or  drainage  of  the  tuberculous 
focus;  the  protection  of  the  affected  tissue  by  proper  mechanical  treatment; 
the  fostering  of  all  attempts  at  normal  bone  cicatrization;  the  use  of  ban- 
dages, fixation  supports,  and  apparatus  for  the  fixation  of  inflamed  joints; 


TUBERCULOSIS   OF    BONES    AND    JOINTS. — BRADFORD.  209 

and,  finallj'-,  the  prevention  or  correction  of  deformities  by  adequate  pro- 
tection during  the  long  period  necessary  for  the  transformation  of  the  ostitic 
bone  to  firm  tissue. 

In  the  past  generation  it  was  taught  that  the  projection  in  a  humpback 
was  to  be  favored  as  the  best  means  of  estabHshing  a  substantial  recovery. 
At  present  a  deformed  spine  is  a  reproach  to  those  in  charge  of  a  child  at- 
tacked with  vertebral  caries.  The  results  in  the  treatment  of  hip  disease, 
i.  e.,  tuberculous  coxitis,  are  now  almost  as  satisfactory. 

The  great  improvement  in  the  treatment  of  bone  tuberculosis  can  be 

seen  if  a  comparison  is  made  between  the  mortality  statistics  of  forty  years 

ago  and  the  results  obtained  in  more  recent  treatment.     The  mortality 

from  hip  diseases  thirty  and  forty  years  ago  reported  in  several  German 

clinics  is  as  follows: 

At  Tubingen 40  per  cent. 

At  Kiel 48.5  "  Non-operative  cases. 

At  Kiel 53  "  Operative  cases. 

At  Marburg 35  "  Non-operative  cases. 

At  Marburg 40  "  Operative  cases. 

At  Heidelberg 46  "  Non-operative  cases. 

At  Heidelberg 50  "  Operative  cases. 

At  Gottingen 40.3  " 

The  improved  results  of  more  careful  special  treatment  were  reported 
fifteen  years  ago  by  Gibney  in  New  York  at  12.5  per  cent.  Menard,  at 
Berck-sur-Mer,  out  of  a  large  number  of  cases  recently  reported  a  mortality 
of  only  7  per  cent.  Accurate  statistics  of  the  Boston  Children's  Hospital, 
in  606  cases,  including  those  operated  upon,  gave  a  4  per  cent,  mortality. 
In  100  cases  where  the  ultimate  result,  ten  years  after  the  end  of  treatment, 
could  be  determined,  including  deaths  from  intercurrent  disease,  the  per- 
centage was  equally  favorable.  It  is  also  true  that  the  functional  results 
obtained  by  careful  treatment  are  equally  satisfactory  in  the  prevention  of 
deformity  and  the  resulting  functional  disability,  so  that  it  may  be  claimed 
that  a  complete  cure  is  possible  in  early  cases  placed  under  favorable  condi- 
tions and  under  proper  care. 

Accurate  statistics  in  Pott's  disease  would  show  in  all  probability  an 
even  more  marked  improvement.  But  statistics  of  Pott's  disease  have  not 
been  as  carefullv  collected  as  of  hip  disease.  Such  as  have  been  collected 
show  so  great  an  improvement  that  it  would  appear  that  the  late  Dr.  Sayre 
was  justified  in  claiming  that  hereafter  there  need  be  no  more  humpbacks. 
Out  of  975  cases  untreated,  reported  by  Rozoy  and  quoted  in  Whitman's 
"Treatise  on  Orthopedic  Surgery,"  there  were  244  deaths.  In  47  cases  with 
paralysis  reported  by  Taylor,  39  recovered  completely,  5  died  of  intercurrent 
disease.  The  mortality,  according  to  Meyer,  in  hospital  cases  was  only 
3  per  cent.  Of  47  cases  of  paraplegia  treated  by  Gibney,  only  9  died.  These 
statistics  refer  more  especially  to  cases  suffering  from  paralysis. 


210  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

An  attempt  was  made  to  find  the  general  mortality  in  cases  which  had 
been  treated  in  the  Boston  Children's  Hospital.  The  inquiry  concerned  only 
the  cases  in  which  the  ultimate  result  could  be  determined  ten  years  after 
treatment.  There  were  38  of  these  cases,  and  of  these,  in  ten  years,  only  3 
had  died;  two  of  these  were  deaths  directly  from  the  results  of  caries  of  the 
spine,  and  one  from  an  undetermined  cause. 

General  Considerations. — The  subject  of  bone  and  joint  tuberculosis  needs, 
in  addition  to  the  study  of  the  results  of  treatment  of  individual  cases,  a 
broader  consideration  of  the  subject.  The  relation  of  the  affected  individual 
to  society  must  be  determined,  as  well  as  what  steps  the  community  should 
take,  not  only  for  the  care  of  the  individual  afflicted,  but  also  toward  the 
protection  of  other  individuals  and  the  prevention  of  the  disease  among 
the  poorer  classes  of  society. 

One  of  the  most  important  considerations  is  the  following:  Should  cases 
with  bone  and  joint  tuberculosis  be  isolated,  or  to  what  extent  are  they  to 
be  isolated?  The  fear  of  tuberculosis  which  has  recently  been  brought  into 
our  communities  is  such  that  the  doors  of  many  charitable  institutions  are 
closed  against  bone  tuberculosis.  There  can  be  no  doubt  that  the  danger 
of  contagion  from  bone  tuberculosis  is  greatly  exaggerated.  It  is  not  prob- 
able that  a  patient  suffering  from  a  tuberculous  focus  in  one  of  the  vertebral 
bodies  is  to  be  regarded  a  source  of  contagion  if  such  a  focus  is  encapsulated. 
There  can  therefore  be  no  danger  in  the  admission  of  such  patients  into  the 
wards  of  a  general  hospital  or  convalescents'  home.  The  same  is  true  of  the 
tuberculous  affection  of  the  hip,  of  the  larger  joints,  or  of  the  osseous  system 
elsewhere.  These  affections  differ  entirely  from  pulmonary  tuberculosis, 
where  the  sputa  offer  a  ready  source  of  contagion.  It  is  to  be  remembered 
that  in  bone  tuberculosis  where  abscesses  have  developed,  the  danger  of 
contagion  can  be  lessened  by  proper  surgical  dressings,  and  the  danger  of 
communication  of  disease  is  no  greater  than  that  from  ordinary  sepsis. 

Home  Care  versus  Institution  Care. — As  the  majority  of  these  cases  occur 
in  children,  home  influences,  when  favorable,  furnish  the  best  environment, 
and  are  preferable  to  institutional  care,  provided,  of  course,  that  home  care 
can  be  thorough,  devoted,  and  continued.  These  conditions  are  not  always 
possible,  and  for  this  reason  a  large  number  of  cases  of  bone  tuberculosis  will 
need  institutional  treatment.  For  it  must  be  admitted  that  the  thorough 
care  of  the  patient  suffering  from  caries  of  the  spine  or  tuberculosis  of  the 
hip  involves  a  considerable  tax  upon  the  nursing  resources  of  the  home. 

Country  Convalescent  Homes. — The  value  of  these  institutions  in  the 
treatment  of  bone  tuberculosis  cannot  be  exaggerated.  Few  homes  furnish 
the  requirements  of  fresh  air  which  can  be  given  in  properly  regulated  con- 
valescent homes.  A  convalescent's  home  should  be  situated  where  it  will 
enable  the  patient  to  enjoy  the  benefit  of  fresh  air  for  as  long  a  period  as 


TUBERCULOSIS   OF   BONES    AND   JOINTS. — BRADFORD.  211 

possible.  Where  convalescents'  homes  are  placed  in  localities  exposed  to 
severe  winters,  especially  to  cold  with  high  humidity,  it  appears  that  patients 
can  have  a  greater  opportunity  of  benefit  from  fresh  air  if  the  convalescent 
home  is  situated  in  a  locality  protected  from  the  fierce  winter  gales  and  severe 
cold  prevalent  along  the  North  Atlantic  coast.  There  are  great  benefits  to  be 
derived,  however,  from  seashore  homes  during  the  hot  months. 

Schools  for  Patients  with  Bone  Tuberculosis. — As  bone  tuberculosis  in  its 
usual  form  requires  for  its  complete  cure  a  long  period  of  time,  children  would 
be  deprived  of  educational  advantages  if,  during  the  convalescent  stage,  they 
were  unable  to  attend  school.  It  is  to  be  remembered  that  large  bone  foci 
not  only  require  time  for  healing,  but  unless  they  are  thoroughly  healed,  so 
that  the  affected  bone  is  capable  not  only  of  weight-bearing,  but  also  of 
resisting  an  unusual  amount  of  jar  with  the  possibility  of  relaxing,  and  that 
under  these  circumstances  school-children  not  only  should  be  free  from  any 
tax  upon  their  constitutional  strength  entailed  by  long  school  hours,  but  also 
should  be  protected  from  the  rough  play  of  schools  -^vith  healthy  children. 
It  is  for  this  reason  that  special  arrangement  of  school  work  is  advisable. 
This  requirement  can  be  met  by  the  establishment  of  special  schools :  these 
can  be  either  the  day-school  or  the  boarding-school.  The  children  in  in- 
stitutions of  this  kind  should  receive  proper  instruction  and  the  regulation  of 
the  hours  of  play,  proper  nourishment,  and  with  the  regulation  of  the  proper 
amount  of  rest  to  prevent  the  exhaustion  of  study  or  play. 

Organization  for  the  Treatment  and  Care  of  Bone  Tuberculosis. — ^The  pre- 
valence of  joint  and  bone  tuberculosis,  especially  in  the  poorer  quarters  of 
our  cities,  is  sufficient  to  justify  organized  attempt  to  check  this  form  of 
tuberculosis.  The  measures  that  will  be  required  are  different  from  those 
which  are  needed  to  eradicate  pulmonary  tuberculosis,  and  may  be  briefly 
summarized  as  follow's: 

The  erection  and  support  of  some  means  for  the  furnishing  of  special 
surgical  treatment,  whereby  operative  interference,  the  furnishing  of  proper 
bandages  or  supports,  and  the  recognition,  record,  and  study  of  these  affec- 
tions are  obtained. 

The  organization  of  a  home  relief  department  which  will  see  that  among 
the  poor  the  necessarj^  treatment  may  be  thoroughly  carried  out  at  home. 

The  establishment  of  convalescent  outdoor  homes  or  seashore  homes 
with  facilities  for  instruction  and  education,  as  well  as  the  nurture,  of  this  class 
of  patients.  These  institutions  and  organizations  should  supplement  the 
organizations  for  the  combating  of  tuberculosis  in  general.  With  the  estab- 
lishment of  such  organizations,  thoroughly  and  efficiently  equipped,  it  would 
be  found  that  not  only  will  bone  and  joint  tuberculosis  be  checked,  but  the 
type  of  the  disease  would  be  gradually  modified  to  such  an  extent  as  to  become 
but  a  slight  menace,  which  will  be  eventually  eliminated  from  our  communities. 


OPEN-AIR   AND    HYPEREMIC    TREATMENT  AS   POW- 
ERFUL AIDS  IN  THE  MANAGEMENT  OF 
COMPLICATED    SURGICAL    TU- 
BERCULOSIS IN  ADULTS. 

By  Willy  Meyer,  M.D., 

New  York. 

Professor  of  Surgery  at  the  New  York  Postgraduate  Medical  School  and  Hospital;  Attending  Surgeon 

to  the  German  Hospital;   Consulting  Surgeon  to  the  New  York  Skin  and  Cancer  Hospital 

and  New  York  Infirmary. 


There  are  some  localities  in  the  body  in  which  bone  tuberculosis,  though 
operable,  cannot  be  cured  by  operation  alone.  Tuberculous  affection  of 
the  OS  sacrum  is  one  type  of  this  class  of  cases;  that  of  the  pelvis,  e.  g.,  aceta- 
bulitis  complicated  with  suppurating  coxitis,  another.  The  persistent  sin- 
uses following  resection  of  the  hip-joint  often  baffle  the  surgeon's  skill  and 
patience. 

Cold  abscess  formation  as  a  result  of  tuberculosis  of  the  pelvis,  especially 
if  recurring  again  and  again,  is  always  a  grave  complication,  and  particu- 
larly so,  in  adults. 

It  is  true,  much  can  be  accomplished  nowadays  by  filling  the  cold  abscess 
cavity  after  evacuation  of  the  pus  through  a  trocar,  with  iodoform  emulsion 
(iodoform  suspended  in  sterilized  glycerin),  following  up  this  process  by 
the  faithful  and  persistent  use  of  hyperemia  for  the  diseased  bone  or  joint. 
Still,  there  are  cases  that  resist  all  our  efforts  in  this  direction.  It  is  here 
that  additional  open-air  treatment  may  become  the  means  also  in  adult 
cases  of  saving  limb  or  life. 

The  literature  in  this  respect,  at  least  in  so  far  as  the  treatment  of  older 
patients  is  concerned,  is  rather  meager.  Halstead,  of  Baltimore,  in  1905, 
read  a  paper  before  the  first  annual  meeting  of  the  International  Associa- 
tion for  the  Study  and  Prevention  of  Tuberculosis,  on  the  Results  of  the 
Open-air  Treatment  of  Surgical  Tuberculosis.  In  said  paper  he  sets  forth 
the  beneficial  influence  of  fresh-air  treatment  in  tuberculous  bone  affections, 
and  gives  his  personal  experience  with  the  method. 

What  has  been  accomplished  in  the  young  with  this   method  is  well 

known.     The  reports  issued  by  the  various  seaside  resorts  abroad,  as  also 

the  Sea-Breeze  Hospital  in  Coney  Island,  maintained  by  the  New  York 

Association  for  Improving  the  Condition  of  the  Poor,  furnish  ample  proof  in 

this  direction. 

212 


OPEN  AIR  AND  HYPEREMIA  IN  SURGICAL  TUBERCULOSIS. — MEYER.       213 

The  following  three  cases,  selected  from  a  number  of  similar  ones  that 
have  come  under  my  care  within  the  last  few  years,  will  serve  to  illustrate  the 
point  in  question: 

Case  I. — Tuberculosis  of  the  os  sacrum,  involving  both  iliosacral  joints 
and  the  fifth  lumbar  vertebra  with  its  articulation. 

Mr.  I.  v.,  who  had  suffered  from  repeated  slight  attacks  of  hemorrhage 
from  the  lungs  during  the  past  few  years,  came  under  my  care  in  April, 
1906,  on  account  of  a  cold  abscess  over  the  left  iliosacral  joint.  The  os 
sacrum  was  swollen  and  tender  in  its  upper  part,  as  was  also  the  neighboring 
pelvic  bone.  In  view  of  the  patient's  reduced  general  condition,  more  serious 
operative  intervention  could  not  be  considered  at  the  time.  The  abscess 
was  evacuated  under  local  ethyl  chlorid  cocain  anesthesia,  and  then  filled 
with  a  5  per  cent,  emulsion  of  sterilized  iodoform  glycerin.  There  was  little 
reaction;  the  patient  was  put  on  a  nourishing  diet  and  remained  under  the 
care  of  a  nurse.  Three  weeks  later  and  again  four  weeks  thereafter,  the 
procedure  had  to  be  repeated,  as  the  abscess  had  refilled.  Soon  afterward 
a  discharging  sinus  formed.  As  the  patient  had  large  business  interests  at 
stake  and  time  was  an  important  item,  the  excision  of  the  iliosacral  articula- 
tion was  seriously  considered.  However,  increasing  sv/elling  and  tenderness 
of  the  right  (opposite)  iliosacral  articulation  rendered  operative  work  out  of 
the  question.  There  could  be  no  doubt  that  the  entire  upper  part  of  the 
OS  sacrum  was  involved  in  the  disease. 

In  former  times  such  a  patient  was  usually  doomed.  To-day  we  have 
learned  that  conservative  methods  of  treatment  may  yet,  at  times,  accom- 
plish a  cure  in  these  cases.  Fortunately,  the  patient  belonged  to  that  class 
that  need  not  count  the  cost  in  trying  to  regain  health. 

Accompanied  by  a  nurse,  he  was  sent  to  the  mountains,  where  he  was  so 
fortunate  as  to  come  under  the  care  of  a  most  thorough  and  learned  colleague. 
He  was  kept  on  his  back,  lived  in  the  open,  day  and  night,  was  put  upon  a 
forced  diet,  had  general  massage  and  proper  internal  medication.  A  typical 
tuberculous  affection  of  the  sheath  of  the  left  Achilles  tendon,  which  had  de- 
veloped within  a  comparatively  short  time,  was  regularly  subjected  to 
hyperemic  treatment  by  means  of  the  elastic  bandage  around  the  thigh. 

After  four  months  he  had  gained  almost  40  pounds,  and  had  to  change 
diet  in  order  to  reduce  his  weight.  The  neighborhood  of  the  sinus  was 
tender  as  before,  also  the  opposite  sacro-iliac  articulation.  Hyperemic 
treatment  by  means  of  suction  glasses  was  now  added.  Regularly  every 
day  a  large  oval  glass  globe,  covering  the  upper  part  of  the  os  sacrum  and 
both  sacro-iliac  articulations,  including  the  immediate  surroundings,  was 
employed,  suction  for  five  or  six  minutes  alternating  with  three-minute 
intermissions.  Half  a  year  later  the  sinus  had  closed  for  the  fifth  time.  It 
reopened  and  healed  temporarily  in  the  course  of  the  following  two  months. 
But  since  the  spring  of  1907  the  scar  has  formed  permanently,  proving  be- 
yond a  doubt  that  the  local  tuberculous  bone  disease  had  healed. 

No  better  proof  could  be  rendered  for  the  existing  depth  effect  of  suction 
hyperemia. 

Meanwhile  pain  and  tenderness  over  the  sacrovertebral  joint  and  fifth 
lumbar  vertebra  itself  had  appeared.  Slowly  a  large  cold  abscess  developed 
in  the  right  lumbar  region,  the  opposite  side  to  that  originally  evacuated. 


214  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

It  is  very  probable  that  the  hyperemic  treatment  caused  this  breaking-down 
of  the  tuberculous  infiltration,  which,  in  the  light  of  Bier's  teachings,  is  to 
be  looked  upon  as  a  favorable  sign.  Slowly  the  pus  traveled  downward 
along  the  iliopsoas  muscle.  When  the  patient  came  to  the  city  for  surgical 
treatment,  in  May,  1907,  a  typical  large  cold  abscess  could  easily  be  made 
out  above  the  upper  half  of  Poupart's  ligament.  Its  development  could  be 
explained  in  no  other  way  than  by  assuming  that  the  sacrovertebral  articu- 
lation as  well  as  the  body  of  the  fifth  vertebra  had  become  complicated  in 
the  disease.  Typical  clinical  symptoms  corroborated  this  diagnosis,  which 
was  also  concurred  in  by  a  prominent  orthopedic  surgeon  who  was  consulted 
at  the  request  of  the  family. 

On  June  7th  the  abscess  was  tapped  under  local  anesthesia.  More  than 
a  quart  of  thin  pus  was  evacuated  through  the  trocar  cannula,  and  100  c.c. 
of  a  5  per  cent,  sterilized  iodoform  glycerin  emulsion  injected  in  its  place. 
Three  weeks  later  the  process  had  to  be  repeated;  a  great  deal  of  the  fluid 
had  reaccumulated.  Of  course,  the  general  treatment  in  all  its  details  was 
strictly  and  regularly  adhered  to  right  along;  also  the  hypodermic  application 
of  tuberculin  (Beraneck's  preparation) ,  which  had  been  begun  several  months 
before,  was  continued  in  increasing  doses  for  twelve  months.  Furthermore, 
a  leather  corset  supported  by  steel  bands  was  procured.  This  was  at  first 
worn  continuously,  the  only  time  of  interruption  being  during  massage  and 
cupping.  Later  on  the  corset  was  left  off  at  night.  The  abdominal  posture 
was  much  favored  by  the  patient.  Early  in  July  he  returned  to  the  moun- 
tains. When  seen  by  me  there  in  September,  the  abscess  had  refilled  to  such 
a  small  extent  that  aspirating,  though  I  came  prepared  to  do  so,  was  not 
done,  it  being  deemed  wiser  to  trust  to  spontaneous  absorption.  At  this 
time  the  bacilli  in  the  sputum  had  entirely  disappeared;  in  fact,  it  had  been 
impossible,  by  the  most  careful  search,  to  detect  the  same  for  over  a  year. 
But  the  patient  complained  of  frequent  accumulation  of  mucus  in  the  throat 
and  trachea.  The  regular  use  of  Kuhn's  lung  suction  mask  was  then  added 
in  the  treatment  of  this  case. 

As  is  well  known,  this  mask  was  designed  for  the  purpose  of  subjecting 
the  lungs  to  suction  hyperemia,  according  to  Bier's  principles. 

Faithfully  the  mask  was  used  by  the  patient,  who  is  impatiently  waiting 
for  the  verdict  "cured."  The  mask  has  been  applied  for  one  hour  twice 
daily  up  to  the  present  time.  The  accumulation  of  mucus  and  the  slight 
hacking  cough  have  disappeared. 

The  localized  tuberculosis  within  the  sheath  of  the  left  tendo  Achillis 
also  has  completely  subsided. 

At  the  time  of  writing  these  lines  the  patient  is  in  excellent  condition. 
He  has  returned  from  the  mountains.  If  no  unforeseen  setback  occurs,  the 
hope  may  be  confidently  entertained  that  another  year,  carefully  spent  with 
no  other  aim  but  to  get  well,  will  suffice  to  restore  the  patient  to  complete 
health. 

Case  II. — Recurrent  Tuberculous  hiflammation  oj  the  Tibiotarsal  Joint 
after  Astragalectomy  Comhined  with  Extirpation  oj  the  Synovial  Membrane. 
Cured  by  Means  of  Hyperemic  Treatment. 

R.  E.  McM.,  male,  sixteen  years  of  age,  consulted  me  in  February,  1906, 
for  a  typical  inflammation  of  the  right  tibiotarsal  joint.  Patient  is  a  slim, 
tall,  anemic  young  man.     Father  has  phthisis.     The  a:-ray  shows  a  typically 


OPEN    AIR    AND    HYPEREMIA    IN    SURGICAL  TUBERCULOSIS. — MEYER.     215 

diseased  astragalus  as  the  cause  (sequestrum).  In  view  of  the  rather  Hmited 
means  of  the  family  and  the  excellent  results  obtainable  in  these  cases  by- 
operation,  conservative  treatment  was  not  favored.  In  February,  1906, 
the  joint  was  opened  according  to  Koenig's  method.  The  astragalus  was 
removed,  the  much  diseased  synovial  membrane  carefully  extirpated,  and  a 
special  incision  added  for  drainage  of  the  joint  on  the  outside  near  the  tendo 
Achillis.  The  three  wounds  were  left  wide  open,  and  the  cavity  was  filled 
with  iodoform  gauze.     The  first  dressing  remained  undisturbed  for  two  weeks. 

Early  in  June  the  patient  was  discharged  with  his  wounds  closed  and 
excellent  motion.  Still,  he  was  not  permitted  as  yet  to  use  the  extremity. 
Equipped  with  crutches  and  the  elastic  bandage,  wliich  he  had  learned  to 
apply  during  the  hyperemic  after-treatment,  he  soon  left  for  Colorado.  He 
improved  rapidly.  Next  spring  found  him  horseback  riding.  He  then 
(May),  unfortunately,  severely  sprained  his  foot.  Pain  and  tenderness  set 
in,  and  several  abundantly  discharging  sinuses  resulted.  He  had  moved  to 
a  camp  in  Wyoming.  I  sent  him  a  set  of  suction  cups  and  an  elastic  rubber 
bandage  for  hyperemic  treatment  of  the  foot,  forbidding  liim  to  use  the 
latter.  Full  directions  were  given  and  changed  from  time  to  time  accord- 
ing to  the  course  of  the  trouble.  Six  months  later  all  wounds  had  closed,  and 
the  pain  and  tenderness  subsided.  He  was  again  warned  against  putting  any 
weight  upon  the  foot  for  some  time. 

He  is  at  the  present  time  still  using  the  artificial  hyperemia. 

A  recurrent  trouble  like  this  would  formerly  have  required  prompt 
surgical  attendance,  several  secondary  operations  might  have  become  neces- 
sary, and,  in  case  of  a  serious  turn  of  the  trouble,  even  amputation  of  the 
leg  might  have  had  to  be  resorted  to.  Fortunately,  tliis  patient,  far  re- 
moved from  direct  medical  aid  as  he  was,  had  sufficient  intelligence  to  carry 
out  properly  the  treatment  on  basis  of  directions  given  from  New  York. 

This  case  represents  another  striking  illustration  of  what  fresh  air  in 
conjunction  with  careful  and  persistent  hyperemic  treatment  can  accomplish 
in  a  comparatively  short  time.  It  also  demonstrates  how  careful  a  patient 
with  a  recently  healed  tuberculous  trouble  should  be  to  avoid  traumatism. 

Case  III. — Tuberculosis  of  the  Right  Hip-joint,  ivith  Multiple  Sinus  Forma- 
tion. Disarticulation  at  Hip-joint;  Involvement  of  Pelvis;  Alive  after  Ten 
Years'  Outdoor  Lije.  Hyperemic  Suction  Treatment  for  Persisting  Sinuses; 
Steady  Improvement. 

On  November  8,  1897,  I  performed  disarticulation  at  the  right  hip  for  a 
long-standing  suppurative  tuberculosis  of  the  joint  in  F.  B.,  a  man,  thirty- 
six  years  of  age.  He  had  seen  many  physicians  and  tried  everything  imagin- 
able. The  entire  upper  half  of  the  femur  was  implicated  in  the  disease, 
and  the  soft  parts  were  riddled  with  discharging  sinuses.  Total  removal  of 
the  lower  extremity  gave  the  only  hope  of  relieving  his  condition.  This  was 
carried  out  with  intra-abdominal  compression  of  the  common  iliac,  through 
an  intramuscular  incision,  according  to  McBurney.  The  method  worked 
admirably;  there  was  very  little  loss  of  blood.  Unfortunately,  it  was  seen, 
after  the  acetabulum  had  been  fully  exposed  following  the  removal  of  the 


216  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

extremity,  that  the  pelvis,  too,  was  extensively  invaded  bj'-  the  disease. 
The  greatly  run  down,  anemic  condition  of  the  patient  forbade  immediate 
additional  resection  of  the  os  ilii.  A  few  months  later,  when  the  patient 
had  sufficiently  recovered,  this  second  operation  was  proposed  to  him,  but 
he  absolutely  refused.  He  asked  me  what  else  he  might  do  to  prolong  his 
life.  I  advised  him  to  buy  a  place  at  the  seashore,  live  there  all  the  year 
around,  and  stay  in  the  open  air  as  much  as  possible.  We  had  to  select  the 
seashore  instead  of  the  mountains,  as  the  patient,  being  dependent  on  his 
business,  wanted  to  go  to  the  city  regularly  as  long  as  his  condition  would 
permit. 

I  then  lost  track  of  him,  and  was  greatly  surprised  when,  in  April  of  this 
year,  I  was  requested  by  a  colleague  to  see  this  patient  with  him  in  a  Long 
Island  seashore  place.  I  had  considered  him  long  dead  and  gone.  Instead, 
I  found  a  still  very  anemic  man,  who,  up  to  a  few  days  ago,  had  gone  to  the 
city  regularly  winter  and  summer,  attending  to  his  business,  having  become 
quite  prosperous.  He  wanted  my  advice  regarding  some  pain  he  had  in  the 
region  of  the  symphysis — a  new  feature  in  his  trouble.  In  looldng  him  over 
and  comparing  his  present  condition  with  that  of  ten  years  ago,  I  found  that 
quite  a  number  of  sinuses  had  closed,  while  others  still  remained  open,  ex- 
tending deeply  into  the  pelvis.  He  had  them  packed  day  after  day  with 
yards  of  narrow  strips  of  gauze  by  his  faithful  wife,  who  had  tenderly  nursed 
him  all  these  many  years.  His  lungs  were  not  affected.  Urinary  examina- 
tion showed  absence  of  albumin. 

I  advised  that  the  packing  be  stopped,  and  Bier's  suction  cups  used  in- 
stead, giving  the  necessary  cUrections. 

Again  I  deeply  regretted  our  present  inability  to  produce  obstructive 
"i^enous"  hyperemia,  the  land  that  is  required  for  the  treatment  of  tuber- 
culous affections  in  the  l^ones  of  the  pelvis  and  hip- joint. 

To-day,  three  months  later,  the  discharge  from  the  sinuses  has  greatly 
decreased,  his  pains  have  disappeared,  and  his  general  health,  too,  is  decid- 
edly improving. 

Pondering  over  this  case,  I  have  been  much  impressed  by  the  salubrious 
effect  of  open  air  in  what  seemed  to  me  an  absolutely  hopeless  case. 

These  three  were  private  patients  of  mine.  They  were  able  to  spend 
money  in  an  effort  to  regain  their  health.  But  how  shall  the  masses — ^the 
hopelessly  poor?  No  adult  patient  afflicted  with  chronic  suppurative  tu- 
berculous bone  disease,  even  with  a  very  slightly  discharging  persistent 
sinus,  can  gain  admission  to  any  of  our  many  country  sanatoriums.  The 
latter  are  thus  far  designed  for  internal  tuberculous  affections  exclusively, 
viz.,  consumption,  not  for  surgical  cases.  And  how  great  an  amount  of 
good  could  be  done,  if  provision  were  made  by  the  State  and  by  our  wealthy 
philanthropists,  to  allow  also  these  poor  sufferers  to  obtain  the  benefit  of 
this  all-important  remedy  for  them,  "fresh  air!" 

I  would,  therefore,  close  my  remarks  with  the  plea  that,  for  the  present, 
two  special  wards — male  and  female — be  set  aside  for  surgical  cases  in  all 
coimtry  sanatoriums  for  consumptives,  and  that  the  special  position  of  sur- 
gical assistant  be  created.     It  is  self-understood  that  such  colleague  would 


OPEN   AIR   AND    HYPEREMIA   IN   SURGICAL  TUBERCULOSIS. — MEYER.      217 

have  to  be  a  man  of  hospital  training  and  fully  conversant  wdth  Bier's  hy- 
peremic  treatment. 

This  arrangement  would  have  to  be  continued  until  the  State  or  philan- 
thropists had  separate  sanatoriums  erected  exclusively  for  the  consei'vative 
treatment  of  adults  suffering  from  surgical  tuberculosis.  I  plead  for  separate 
sanatoriums  for  the  reason  that  the  majority  of  these  patients  are  not 
afflicted  with  complicating  tuberculous  affection  of  the  lungs. 

If  a  number  of  private  rooms  were  set  aside  in  such  sanatoriums  for 
surgical  tuberculosis,  the  income  derived  from  this  source  would  be  a  material 
help  in  defraying  running  expenses. 


El  Aire  Pure  Combinado  con  el  Tratamiento  Hiperemico  en  los  Cases 

Quinirgicos  de  Tuberculosis  de  los  Huesos  en  el 

Adulto. — (Meyer.) 

La  infiuencia  benefica  del  aire  puro  en  los  casos  quiriirgicos  de  tuber- 
culosis de  los  huesos  es,  en  los  ninos,  generalmente  reconocida.  No  asi  en 
los  adultos.  En  los  ultimos  la  operacion  radical  ha  sido  el  tratamiento, 
de  costumbre  hasta  la  fecha  y  probablemente  continuara  siendolo,  siempre 
que  la  economia  de  tiempo  sea  uno  de  los  factores  que  deben  tenerse  en 
cuenta,  6  cuando  no  haya  suficientes  medios  a  mano. 

Las  liistorias  de  tres  casos  complicados  de  tuberculosis  de  los  huesos 
en  adultos  se  muestran  para  demostrar  cuanto  puede  alcanzarse  aun  en 
los  casos  que  de  costumbre  se  consideran  tratables,  especialmente  si  se 
combina  con  fieles  y  apropiados  metodos  de  tratamiento  hiperemico  en 
sus  diversas  formas. 

Se  pide  que  en  los  sanatorios  hoy  designados  para  pacientes  que  sufren 
de  tuberculosis  pulmonar  se  dediquen  dos  salas,  a  lo  menos,  (para  hombres 
y  mujeres)  para  el  tratamiento  de  los  casos  quirurgicos  de  tuberculosis 
de  los  huesos  en  el  adulto,  que  por  razones  varias,  no  podrian  6  no  deberian 
sujetarse  a  operacion.  Naturalmente  los  medicos  de  asistencia  y  enfer- 
meras  de  estas  salas,  deberian  dominar  por  complete  todos  los  detalles 
del  tratamiento  hiperemico. 


Du  traitement  par  I'air  frais  combine  avec  le  traitement  par  Thyperemie 
dans  les  cas  chirurgicaux  de  tuberculose  compliquee 
des  OS  chez  les  adultes. — (Meyer.) 
L'influence  bienfaisante  de  I'air  frais  dans  les  cas  chirurgicaux  de  tuber- 
culose des  OS  chez  les  enfants  est  g^n^ralement  admise.    Ce  n'est  pas  ainsl 
chez  les  adultes.    Ceux-ci  ont  6tc  trait^s  principalement  par  I'opcration 


218  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

radicale  jusqu'^  present  et  continueront  probablement  a  etre  traites  de 
cette  maniere  dans  tons  les  cas  ou  il  faut  epargner  du  temps,  ou  bien  la  ou 
Ton  ne  dispose  pas  de  moyens  suffisants. 

L'auteur  cite  trois  cas  de  tuberculose  chirurgicale  corapliquee  des  os 
chez  des  adultes,  par  lesquels  il  montre  quels  bons  rcsultats  on  pent  obtenir 
meme  dans  les  cas  ordinairement  refractaires,  surtout  si  I'air  frais  et  combine 
avec  le  traitement  hyperemique,  dans  ses  differentes  formes,  applique 
proprement  et  consciencieusement. 

L'auteur  demande  que,  dans  les  sanatoria  qui  maintenant  sont  destinds 
a  recevoir  les  malades  atteints  de  tuberculose  pulmonaire,  on  pourvoie  au 
moins  deux  di\'isions  (pour  hommes  et  pour  femmes)  ou  Ton  soignerait  les 
cas  de  tuberculose  chirurgicale  des  os  des  adultes,  que,  pour  une  raison  ou 
pour  I'autre,  on  n'a  pas  pu  operer.  Bien  entendu,  les  medicins  et  les 
garde-malades  de  ces  divisions  doivent  connaitre  parfaitement  les  details 
du  traitement  hyper6mique. 


Frische  Luft,  combinirt   mit  Hyperamie,  angewandt  in  der  Behandlung 

complizirter  chirurgischer  Falle  von  Knochentuberkulose 

bei  Erwachsenen. — (Meyer.) 

Der  wohltiitige  Einfluss  der  frischen  Luft  in  chirurgischen  Fallen  von 
Knochentuberkulose  bei  Kindern  ist  allgemein  bekannt.  Nicht  so  bei 
Erwachsenen.  Bei  den  letzteren  war  die  Radikal-Operation  bisher  die 
gewohnliche  Behandlung  und  wird  es  wahrscheinlich  bleiben,  wo  immer 
Zeitersparnis  als  erwagenswerter  Faktor  in  Betracht  kommt,  oder  genii- 
gende  jMittel  nicht  zur  Hand  sind. 

Die  Krankheitsgeschichten  dreier  Falle  von  complizirter  Knochentuber- 
kulose bei  Erwachsenen  sind  vorhanden,  um  zu  beweisen,  wieviel  sogar 
in  fiir  gewohnlich  als  nicht  behandelbar  geltenden  Fallen  getan  werden 
kann,  ganz  besonders,  wenn  Combinationen  der  hyperamischen  Behandlung 
in  ihren  verschiedenen  Formen  ordentlich  und  griindlich  angewendet  werden. 
Es  ist  der  Vorschlag  gemacht  worden,  in  den  jetzt  fiir  an  Lungentuberkulose 
leidenden  Patienten  bestimmten  Heilanstalten  zum  mindesten  zwei  Ab- 
teilungen  (mannlich  und  weiblich)  fiir  die  Behandlung  Erwachsener,  an 
chirurgischer  Knochentuberkulose  Erkrankter,  einzurichten,  die  aus  ver- 
schiedenen Griinden  sich  einer  Operation  nicht  unterziehen  komiten  oder 
wollten.  Selbstverstandlich  sollen  die  in  solchen  Abteilungen  angestellten 
Arzte  und  Krankenpflegerinnen  die  Details  der  Hyperamie-Behandlung 
vollig  beherrschen. 


THE  SURGICAL  TREATMENT  OF  TUBERCULOUS 
SINUSES  AND  THEIR  PREVENTION. 

By  Emil  G.  Beck,  M.D., 

Surgeon  to  the  North  Chicago  Hospital,  Chicago. 


The  sldll  and  wisdom  of  the  medical  profession  have  been  taxed  to  the 
utmost  in  perfecting  the  method  of  treating  suppurative  sinuses,  but  their 
efforts  have,  until  recently,  not  been  entirely  successful.  As  evidence  of 
this  fact  we  may  point  to  the  invalids  who,  for  years,  have  received  the  most 
skilful  treatment,  and  have  submitted  to  repeated  and  often  dangerous 
and  mutilating  operations,  without  having  been  materially  benefited. 

A  confession  of  our  inability  to  deal  with  this  class  of  affections  is  the 
scant  information  wliich  our  best  text-books  give  us  on  the  treatment  of  this 
serious  and  prevalent  ailment.  The  following  quotation  from  the  latest 
edition  of  Keen's  "Surgery"  is  an  example  of  the  extent  to  which  the 
therapy  of  this  subject  is  treated: 

"Tuberculous  sinuses  are  troublesome  because  of  their  refusal  to  heal 
until  all  infective  material  has  been  removed,  and  sometimes  this  is  im- 
possible, even  though  the  most  serious  and  extensive  operations  are  resorted 
to.  As  instances  may  be  cited  spinal  caries,  hip  disease,  and  white  swelling 
of  the  knee." 

This  is  a  sad  commentary  upon  our  fighting  ability  to  cope  with  a  malady 
so  wide-spread  and  destructive,  one  which  selects  its  victims  from  the  poorer 
classes,  who  are  least  fortified  to  withstand  the  hardships  which  invalidism 
imposes,  an  ailment  which  keeps  thousands  of  children  in  pain,  confinement, 
and  helplessness,  and  when  it  does  not  kill,  often  cripples  for  life.  These 
unfortunate  persons  are  likewise  a  source  of  danger  to  those  who  surround 
them,  the  tuberculous  infection  being  spread  by  the  secretions  from  their 
fistula.* 

Meeting  with  failure,  surgeons  have  naturally  directed  their  efforts  to 
prevention  rather  than  cure.  Since  sinuses  or  fistula  themselves  are  not 
diseases,  their  prevention  must  be  sought  in  fighting  the  cUsease  which 
causes  them,  and  whenever  this  disease  cannot  be  checked,  such  measures 
of  treatment  and  prevention  must  be  used  as  will  guard  against  the  forma- 
tion of  sinuses. 

*Garre:  Deutsche  med.  Wochenschrift,  1905,  p.  47. 
219 


220  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

The  terms  sinus  and  fistula  are  often  used  interchangeably.  In  this  paper 
the  term  "sinus"  will  refer  to  suppurative  channels  or  tracts  leading  into 
blind  pockets  or  cavities  in  bone  or  parenchymatous  tissues,  while  the  term 
"fistula"  will  apply  to  suppurative  tracts  leading  to  hollow  organs. 

We  shall  here  consider  the  fistulous  tracts  and  sinuses  of  tuberculous 
origin,  only  first  reviewing  the  principal  methods  of  their  prevention  and 
treatment  now  in  vogue,  and  then  discuss  a  new  method  of  diagnosis,  pre- 
vention, and  treatment  which  I  shall  have  the  privilege  of  presenting  to  you. 
■  The  orthopedic  surgeons  have  proved  that,  by  rest,  proper  immobilization 
of  the  affected  parts,  and  general  treatment,  tuberculous  disease  of  the  joints 
may  be  arrested,  and  in  a  large  percentage  of  cases  the  patients  restored  to 
perfect  health  without  any  surgical  interference.  This  form  of  treatment 
in  itself  is  of  great  value  in  the  prevention  of  sinuses.  All  cases,  however, 
do  not  yield  to  this  course  of  treatment,  and  some  more  radical  measure  is 
required.  Injection  into  the  joints  of  a  10  per  cent,  iodoform-glycerin 
emulsion,  or  a  1  to  5  per  cent,  solution  of  carbolic  acid,  and,  lately,  the  for- 
malin-glycerin solution,  advocated  by  Dr.  John  B,  Murphy,  have  been  found 
effective  in  destroying  the  tuberculous  process  and  restoring  the  limb  to 
comparative  usefulness.  Where  the  disease  has  destroyed  the  synovia, 
perforated  the  cartilage,  or  where  the  epiphyses  are  the  seat  of  tuberculous 
disease,  still  more  radical  surgery  is  necessary,  such  as  either  the  erasion  or 
resection  of  the  joint,  as  the  case  may  require.  In  extreme  cases  an  impu- 
tation is  sometimes  necessary  in  order  to  save  the  patient's  life. 

The  more  recent  advances,  such  as  Professor  Bier's  hyperemia  treatment, 
the  application  of  x-rays,  and  lately  the  subcutaneous  injections  of  Koch's 
tuberculin,  under  the  guidance  of  the  opsonic  index,  have  their  advocates 
in  the  treatment  of  tuberculous  joints,  and  although  their  value  has  not  yet 
been  definitely  determined,  they  must,  nevertheless,  be  considered  as  very 
important  factors  in  the  indirect  prevention  of  tuberculous  sinuses.  With 
the  methods  here  enumerated  most  cases  will  recover.  Some  cases,  how- 
ever, will  resist  all  efforts  to  prevent  abscess  formation. 

Even  though  an  abscess  has  formed,  the  sinus  can  still  be  prevented. 
By  rest  in  bed  the  abscess  may  disappear  by  absorption.  Its  incision  and 
drainage  have  heretofore  been  discouraged,  on  account  of  the  danger  of 
secondary  infection  which  usually  follows.  In  many  instances,  however, 
the  abscess  ruptures  spontaneously,  and  a  sinus  or  fistula  is  inevitable. 
After  the  sinus  has  once  formed  and  there  is  no  natural  tendency  to  spon- 
taneous closure,  it  will  persist  in  discharging  pus  indefinitely. 

The  irrigation  of  fistulous  tracts  or  abscess  cavities  with  solutions,  such 
as  the  silver  salts  or  iodin,  olive  oil  with  turpentine,  permanganate  of  potash, 
and  various  other  solutions,  which  at  one  time  was  the  routine  treatment 
of  these  affections,  has  now  been  discarded  by  all  progressive  surgeons,  and 


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PREVENTION    AND   TREATMENT   OF   TUBERCULOUS   SINUSES. — BECK.     221 

those  who  have  had  the  widest  experience  with  this  class  of  cases  have  con- 
cluded that,  aside  from  the  prophylactic,  hygienic,  and  dietetic  treatment, 
surgery  is  the  only  means  which  has  been  to  any  degree  effective  in  curing 
tuberculous  sinuses.  However,  even  here  surgery  has  a  limited  field.  It 
will  fail  where  the  fistula  cannot  be  traced  to  its  origin  and  be  completely 
eradicated.  Unfortunately,  this  is  often  the  case,  because  the  sinus  often 
leads  into  inaccessible  regions,  such  as  the  sinuses  following  tuberculous 
spondylitis.  Again,  the  sinuses  are  often  so  extensive  and  undermine  such 
large  areas  that  their  extent  cannot  be  estimated.  A  successful  surgical 
operation  depends  upon  a  correct  anatomical  diagnosis.  In  no  other  affec- 
tion is  this  more  important  than  in  the  operative  treatment  of  fistulous  tracts. 

Anatomical  Diagnosis. — June  13,  1906,  I  demonstrated  before  the 
Chicago  Medical  Society  a  new  method  of  anatomical  diagnosis  of  fistulous 
tracts,  advised  by  my  brother,  Dr.  Carl  Beck.  This  method  consists  of  fill- 
ing the  fistulous  tract  or  abscess  cavity  with  a  paste  made  of  33  per  cent, 
bismuth  subnitrate  and  66  per  cent,  of  vaselin,  and  then  taking  a  radiograph 
of  the  region  so  injected.  This  paste  is  liquefied  by  heating  before  injec- 
tion, and  it  requires  only  moderate  pressure  to  force  the  liquid  into  all 
recesses  of  the  sinus. 

It  is  well  known  that  bismuth  offers  great  resistance  to  the  penetration 
of  the  .T-ray,  and,  therefore,  it  is  a  suitable  material  for  this  class  of  radio- 
graphic work.  A  radiograph  taken  by  this  method  clearly  shows  the  boun- 
daries of  the  fistulous  tracts  or  cavities,  tracing  distinctly  the  ramifications 
of  the  same,  no  matter  how  extensive  and  tortuous  they  may  be.  Stereos- 
copic radiographs  are  still  more  valuable,  as  they  mform  us  of  the  depth  and 
relation  of  sinuses  to  other  structures.  The  most  unexpected  and  surprising 
findings  are  often  thus  obtained.  (See  Figs.  1  and  2.)  In  cases  where  re- 
peated surgical  operations  have  failed  to  effect  a  cure,  these  radiographs  have 
disclosed  the  cause  of  the  failure.  They  demonstrate  that  the  surgeon's 
incorrect  anatomical  diagnosis  was  the  cause  of  the  failure,  many  ramifica^ 
tions  having  been  left  unexplored  after  what  he  considered  a  radical  opera- 
tion had  been  performed.  With  but  hmited  means  for  exploration,  then, 
at  the  disposal  of  the  surgeon,  this  was  not  surprising.  The  probe,  which 
was  generally  used,  is  unrehable,  for  obvious  reasons.  It  may  slip  into  one 
straight  sinus,  and  cause  us  to  conclude  that  this  is  the  only  one  existing, 
while,  in  fact,  the  area  may  be  undermined  by  a  network  of  sinuses. 

The  staining  of  fistulous  tracts  by  the  injection  of  colored  fluids,  such  as 
methylene-blue,  for  a  guide  during  the  operation,  is  likewise  unreliable. 
The  stain  may  run  through  only  one  large  patulous  sinus,  the  narrow  ones 
remaining  collapsed,  owing  to  insufficient  pressure  to  distend  them.  More- 
over, the  stained  tracts  become  very  much  discolored  by  blood  during  the 
operation,  so  that  they  cannot  be  traced.     Neither  can  one  study  the  extent 


222  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

of  the  disease  before  the  operation.  The  sinus  may  extend  into  inaccessible 
regions,  and  this  fact  may  not  be  discovered  until  the  patient  has  been  on 
the  operating  table  for  an  hour  or  two. 

The  employment  of  peroxid  of  hydrogen  for  diagnostic  purposes  has  no 
other  value  than  to  aid  us  in  ascertaining  whether  a  fistula  communicates 
with  a  hollow  organ  or  with  another  fistula. 

By  our  new  method,  if  properly  carried  out,  it  is  almost  impossible  to 
miss  any  of  the  sinuses.  We  have  a  pictiu-e  of  the  entire  diseased  tract 
before  our  eyes,  and  are  thereby  enabled  to  discriminate  between  operable 
and  inoperable  cases,  whereas  formerly  we  had  to  first  perform  the  operation 
in  order  to  find  out  whether  the  case  was  operable  or  not. 

Eliminating  the  inoperable  cases  with  the  aid  of  this  new  method,  and 
selecting  one  which  is  operable,  a  well-known  surgical  principle  must  be 
carried  out  in  order  to  effect  a  cure,  namely,  the  thorough  eradication  of  all 
diseased  tracts  and  tissues.  Caries  of  bone  or  tuberculous  granulation  must 
be  cureted  or  excised,  so  that  the  diseased  tract  is  converted  into  a  healthy 
wound,  which  should  heal  by  healthy  granulations.  The  healing  of  bone 
defects  created  by  cureting  has  been  aided  by  filling  them  with  foreign  sub- 
stances. Filling  such  a  cavity  with  a  sponge  in  the  hope  that  it  might  serve 
as  a  framework  for  bony  growth  was  once  practised,  but  has  properly  been 
given  up.  Later  a  method  of  filling  the  cavity  with  a  blood-clot  (Schede) 
was  introduced.  This,  however,  was  applicable  only  in  cases  where  the 
cavity  could  be  perfectly  sterilized,  and  for  this  reason  its  application  was 
very  limited.  Another  method  which  has  some  advantage  over  the  blood- 
clot  is  that  of  filling  the  cavity  with  decalcified  bone-chips,  advocated  by  the 
late  Professor  Senn.  In  selected  cases  Neuber's  method  may  be  employed, 
which  consists  in  removing  a  portion  of  the  cortical  bone  shell  surrounding 
the  cavity  and  then  inverting  skin-flaps  from  either  side,  for  the  purpose 
of  lining  and  obliterating  the  cavity.  The  Mosetig-Moorhof  "Plombirung" 
has  become  a  favorite  method  in  obliterating  these  bony  defects.  It  consists 
in  sterilizing  and  drying  out  the  bone  cavity  and  then  pouring  in  a  heated 
mixture  of  iodoform,  spermaceti,  and  oil  of  sesame,  which  solidifies  on  cool- 
ing. The  soft  structures  are  then  sutured  over  this  waxy  plug,  and  primary 
union  and  cure  often  follow.  Other  substances,  such  as  gutta-percha, 
plaster-of-Paris,  filigree  silver)  wire,  have  been  used,  mostly  in  experimental 
work. 

Rectal  fistulas  are  usually  treated  by  slitting  them  into  the  rectum,  curet- 
ing all  accessible  branches,  and  then  allowing  them  to  heal  by  granulation. 

There  remains  a  class  of  cases  which  will  yield  to  none  of  these  methods, 
neither  prophylactic  nor  curative,  namely,  the  sinuses  extending  into  in- 
accessible regions.  These  individuals  are  a  nightmare  to  the  surgeon,  a 
touching  sight  to  the  public,  and  a  burden  to  themselves. 


PREVENTION    AND   TREATMENT   OF   TUBERCULOUS   SINUSES. — BECK.     223 

The  new  method  of  treatment  which  we  wish  to  present  for  your  con- 
sideration is  apphcable  to  practically  all  cases  of  this  dreadful  affection,  in- 
cluding even  those  cases  which  have  heretofore  been  considered  hopeless. 
I  refer  to  the  injection  of  bismuth-vasehn  paste  for  therapeutic  purposes. 
This  paste,  which  we  at  first  used  for  diagnostic  purposes  only,  has  now 
proved  to  be  of  the  greatest  value  in  the  treatment  of  tuberculous  sinuses  and 
abscess  cavities.  The  extent  of  its  value  was  not  fully  appreciated  until 
August,  1907,  w^hen  we  noticed  that  patients  on  whom  we  employed  the  in- 
jection for  diagnostic  purposes  returned  to  us  after  months  entirely  cured. 
This  at  once  suggested  to  me  the  use  of  the  bismuth-vaselin  paste  for  cura- 
tive effects,  whereupon  a  number  of  obstinate  cases  were  at  once  injected, 
and  in  each  case  the  result  was  most  gratifying,  namely,  a  rapid  closure  of 
the  sinuses. 

On  January  15,  1908,  I  reported  14  cases  to  the  Chicago  ]\Iedical  Society, 
all  treated  by  this  method,  10  of  which  were  then  demonstrated. 

This  series  consisted  of  two  cases  of  spondyUtis  and  psoas  abscess,  one  of 
two  years'  and  one  of  sixteen  years'  duration.  Two  cases  of  tuberculous 
hip-joint,  one  of  nine  years'  and  one  of  sixteen  years'  duration.  One  case  of 
tuberculous  knee-joint,  seven  years'  duration.  One  case  of  tuberculosis  of 
pelvic  bones  of  three  years'  duration.  One  case  of  tuberculosis  of  the  ulna  of 
six  months'  duration.  One  case  of  fistula  after  removal  of  tuberculous 
kidney  of  one  year's  duration.  Three  cases  of  rectal  fistula,  one  of  two 
years',  one  of  one  year's,  and  one  of  six  months'  duration.  Two  cases  of 
abdominal  fistula  following  laparotomy,  one  of  four  months'  and  one  of  one 
year's  duration.  One  case  of  tuberculosis  of  metacarpal  bone,  one  year's 
duration. 

Of  these  14  cases,  10  had  then  been  cured,  2  improved,  and  2  not  im- 
proved. Since  that  time  3  of  the  latter  have  healed  entirely,  so  that  only  1 
case  of  this  series  remains  uncured.  This  case  (No.  1,  Table  H,  Series  3) 
is  a  tuberculous  spondylitis  of  sixteen  years'  duration,  with  nine  discharging 
sinuses  and  several  sequestra.  The  patient  has  thus  far  received  130  in- 
jections and  is  somewhat  improved. 

This  method  has  since  been  tested  by  many  of  our  noted  surgeons,  and 
their  reports  indicate  that  they  have  obtained  equally  good  results. 

It  is  my  intention  to  present  to  this  Congress  a  collective  report  of  cases 
treated  by  this  method,  the  records  of  which  I  shall  obtain  through  the  cour- 
tesy of  the  larger  general  hospitals,  the  United  States  Army  and  Navy 
Hospitals,  and  private  practitioners.  At  this  writing  (July  20th)  it  is, 
however,  too  early  to  have  obtained  these  reports.  I  have,  therefore,  con- 
cluded, for  the  present,  to  report  only  three  series  of  cases  treated  in  various 
Chicago  institutions.    The  summary  is  as  follows; 


224  SIXTH   INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

Series     1. — Augustana     Hospital,     Chicago.      Report     of     Drs.     A.    J.     and 

E.    H.    OCHSNER. 

TABLE  A. — Number  of  cases  cured 8 

TABLE  B. — Number  of  cases  still  under  treatment 9* 

17 

Series    2. — Home    for   Destitute    and    Crippled    Children,    Chicago.     Report 
BY  Drs.  Ridlon  and  Blanchard. 

TABLE  C. — Number  of  cases  cured 9 

TABLE  D. — Number  of  cases  cured  by  prophylactic  method 2 

TABLE  E. — Number  of  cases  still  under  treatment 13t 

24 

Series  3. — North  Chicago  Hospital,  Chicago.     Report  by  Drs.  Carl,  Joseph  C, 

AND  Emil  G.  Beck. 

TABLE  F. — Number  of  cases  cured 26 

TABLE  G. — Number  of  cases  treated  by  prophylactic  method 6$ 

TABLE  H. — Number  of  cases  still  under  treatment 10  § 

42 

TOTAL. —  Cases  cured  by  bismuth  injections "^^  ^  60      per  cent 

Cases  cured  by  prophylactic  method 7/  ^ 

Cases  improved 22  26 . 5  per  cent. 

Cases  treated  one  week,  results  awaited 5  6      per  cent. 

Cases  not  improved 6  7.5  per  cent. 

83 

For  illustration  of  the  method  and  its  results,  three  typical  cases  are  here 
cited,  each  exemplifying  a  different  type  of  tuberculous  sinuses: 

Series  3,  Table  F. — Case  2. — M.  Y.,  aged  fourteen,  born  in  Germany; 
lived  there  until  1903;  family  history  negative.  He  was  healthy  until  he 
was  seven  years  old,  when  he  developed  a  painful  swelling  in  his  right  knee. 
A  cast  was  put  on  by  his  family  physician  for  the  purpose  of  immobilization. 
In  a  short  time  an  abscess  ruptured,  the  boy  was  transferred  to  the  hospital 
at  Freiburg,  in  Germany,  and  an  operation  was  performed  for  tuberculosis  of 
the  knee-joint.  He  left  the  hospital  seven  weeks  later  with  a  sinus  extending 
from  the  knee-joint  into  the  middle  of  the  tibia,  and  two  smaller  ones  near 
the  joint. 

A  short  time  later  he  returned  to  the  hospital  for  another  operation, 
which,  however,  failed  to  close  the  sinuses,  and  a  third  operation  was  per- 
formed two  months  later,  again  with  an  unfavorable  result.  The  parents 
then  took  the  l)oy  to  Tubingen,  where  Professor  Bruns  performed  the  fourth 
operation.  No  improvement,  however,  resulted,  and  three  fistulas  persisted 
as  before.  The  family  then  moved  to  America,  in  June,  1903.  They  had 
abandoned  all  medical  treatment;  nothing  more  than  daily  dressing  was  done 
by  the  patient  himself. 

*  Of  the  9,  7  are  improved  and  2  unchanged. 

t  Of  the  13  cases,  5  are  improved;  5  have  been  treated  only  one  week,  results  awaited; 
3  are  unchanged. 

I  Of  the  6  cases,  5  are  cured  and  1  is  improved,  results  being  awaited. 

§  Of  the  10  cases,  6  show  marked  improvement,  3  some  improvement,  1  remains 
unchanged. 


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PREVENTION    AND   TREATMENT   OF   TUBERCULOUS   SINUSES. — BECK.     225 

On  March  21,  1907,  at  the  age  of  thirteen,  six  years  after  the  commence- 
ment of  the  fistula,  he  came  to  me  for  treatment.  A  radiograph  without 
bismuth  injection  was  first  taken.  It  shows  the  joint  and  the  epiphyses  of 
femur  and  tibia  nearly  destroyed,  and  a  sequestrum  is  clearly  visible  in  the 
tibia.  I  proposed  an  operation,  namely,  the  resection  of  the  knee-joint, 
which  was  refused.  I  then  decided  on  the  next  best  procedure,  and  cleaned 
out  the  knee-joint,  removing  the  sequestrum  as  radically  as  possible.  This 
was  done  March  29,  1907,  with  the  same  result,  namely,  three  fistulas  per- 
sisted. I  then  decided  to  try  Professor  Bier's  hyperemia  method,  which  was 
carried  out  for  four  months,  but  without  result.  By  this  time  our  experi- 
ments with  bismuth  injections  were  so  promising  that  I  decided  to  try  it  in 
this  case  for  therapeutical  purposes. 

The  first  bismuth  paste  injection  was  made  October  3,  1907,  and  fistula 
at  once  showed  the  tendency  to  healing.  After  three  injections,  at  intervals 
of  one  week,  the  sinuses  became  nearly  closed,  and  I  could  only  with  difficulty 
make  the  fourth  injection,  of  which  I  took  a  radiograph  (Fig.  3).  Since  that 
time  all  fistulas  remained  healed,  the  boy  became  stronger,  the  pain  entirely 
disappeared,  so  that  he  could  discard  his  crutches,  which  he  had  used  for 
seven  years.  He  can  now  skip  up  and  dowTi  stairs  on  the  tuberculous  limb. 
His  weight  has  increased  fifteen  pounds. 

Case  21. — Miss  M.  W.,  aged  thirteen  years,  was  well  until  her  seventh 
year,  when  she  fell,  striking  her  hip.  No  serious  consequences  were  dis- 
covered until  1904,  when  she  was  taken  to  St.  Joseph's  Hospital  in  Chicago, 
where  the  late  Professor  Senn  diagnosed  her  case  as  tuberculosis  of  the  hip; 
injected  a  10  per  cent,  iodoform-glycerin  emulsion,  and  put  the  limb  into  a 
plaster-of-Paris  cast.  Three  months  later  the  cast  was  removed,  and  from 
that  time  the  injections  were  repeated  until  nine  had  been  given.  An  ab- 
scess formed,  which  ruptured  on  the  external  side  of  her  thigh,  near  the 
middle  of  the  femur.  The  sinus  resulting  therefrom  kept  on  discharging  a 
large  quantity  of  green,  malodorous  pus  for  three  years,  and  required  daily 
dressings.  She  was  unable  to  move  about  without  the  aid  of  crutches, 
owing  to  the  tenderness  in  her  hip. 

On  February  28,  1908,  when  we  first  saw  her,  she  was  very  much  emaci- 
ated, pale  and  weak,  with  a  shortening  of  9  cm.  in  her  left  lower  limb,  and  a 
sinus  on  the  anterior  surface  of  her  left  thigh,  discharging  pus,  was  found. 

A  radiograph  taken  demonstrated  the  destruction  of  the  head  of  the 
femur.  A  second  stereoscopic  radiograph  (Fig.  4),  taken  after  the  first 
bismuth  paste  injection  had  been  given,  demonstrated  that  the  sinus  ex- 
tended from  the  opening  on  her  thigh  upward  in  front  of  the  greater  trochan- 
ter, winding  its  way  backward  toward  the  acetabulum,  and  there  filling  a 
small  cavity  in  front  of  the  ramus  of  the  ischium. 

The  discharge  diminished  after  the  first  injection,  and  its  character  was 
changed  to  a  seropurulent  fluid  resembling  dirty  water.  Repeated  micro- 
scopical examinations  of  the  pus  discharge  proved  the  gradual  disappearance 
of  the  staphylococci  and  streptococci,  which,  before  the  injections  were  given, 
were  found  in  abundance.  After  twenty  injections  during  a  period  of  four 
months  the  sinus  healed. 

Case  7. — J.  P.,  aged  eighteen.  Family  history:  Father  and  mother 
living  and  well;  three  sisters  and  two  brothers  well;  one  sister  died  from 
bronchial  trouble;  one  baby  sister  from  tuberculosis. 


226  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

Past  history:  About  a  year  ago  he  had  chills,  fever,  and  pain  about  the 
rectum.  An  abscess  formed  and  broke  at  a  point  one  inch  from  the  anus. 
Sinus  persisted  up  to  the  time  of  examination.  Operation  was  performed 
May  10,  1906.  The  sinus  was  slit  open  into  the  rectum,  all  visible  recesses 
were  thoroughly  cureted  and  packed  with  iodoform  gauze.  After-treatment 
consisted  of  daily  irrigation  with  boric  acid  and  cauterization  with  20  per 
cent,  silver  nitrate,  but  fistula  showed  no  tendency  to  heal. 

Bismuth  paste  was  then  injected  into  the  sinus  for  diagnostic  purposes 
only  (Fig.  5).  This  clearly  demonstrated  why  we  had  no  success  in  the  first 
operation,  because  another  sinus  existed  higher  up,  which  communicated 
by  a  constriction  with  the  fistula  operated  upon.  Another  operation  was 
at  once  decided  upon  and  performed  on  July  7,  1906,  and  the  sinus,  extend- 
ing about  two  inches  in  the  direction  of  the  prostate,  was  cureted.  From 
this  time  on  the  healing  went  on  rapidly.  Patient  slept  out-of-doors,  gained 
about  twenty  pounds  in  weight,  and  was  discharged  cured  by  September  7, 
1906,  and  has  remained  so  up  to  date. 

Technic. 
The  technic  is  as  follows:  Two  different  preparations  of  bismuth  paste 
are  used,  each  having  a  different  melting-point. 
No.  1  consists  of: 


Bismuth  subnitrate 33  per  cent. 

Vaselin  (petrolatum) 67       " 


i 


This  preparation  is  used  for  diagnostic  purposes  and  the  early  part  of 
the  treatment. 
No.  2  contains: 

Bismuth  subnitrate 30  per  cent. 

White  wax 5       " 

Paraffin  (120°  melting-point) 5 

Vaselin  (petrolatum) 60       " 

The  latter  formula  is  used  in  the  later  part  of  the  treatment,  where  it  is 
desired  to  retain  the  paste  within  the  sinuses,  and  where  there  is  no  danger 
of  producing  retention  of  pus  by  obstructing  narrow  connecting  channels. 

These  preparations  may  be  modified  to  suit  individual  cases.  They 
may  be  made  firmer  and  of  a  higher  melting-point  by  increasing  the  propor- 
tion of  wax  and  paraffin.  At  times  it  is  advisable  to  use  a  smaller  percent- 
age of  bismuth. 

The  vaselin,  wax,  and  paraffin  are  sterilized  by  boiling,  and  the  bismuth 
subnitrate  gradually  stirred  in  after  the  mixture  has  been  removed  from  the 
fire.  This  will  produce  a  yellow,  homogeneous  liquid,  which,  on  cooling, 
will  form  two  layers.  The  heavier  bismuth  will  gravitate  and  leave  a  layer 
of  vaselin  on  the  surface.  It  is  therefore  necessary  to  heat  and  stir  the 
mixture  before  using.  Accidental  admixture  of  water  during  the  prepara- 
tion will  destroy  the  homogeneous  quality  and  interfere  with  its  retention 
within  the  sinuses. 


prevention  and  treatment  of  tuberculous  sinuses. — beck.   227 

Instruments. 
The  only  instrument  used  is  a  glass  syringe  with  a  pointed  nozle,  simUar 
to  the  urethral  syringes.     Fig.  No.  6  is  that  of  a  syringe  which  we  have  used 
with  satisfaction.     It  can  be  obtained  in  several  sizes,  and  some  modifica- 
tions to  suit  different  cases. 

Preparation  and  Injection  of  Sinuses. 
Originally  we  attempted  drying  the  fistula  by  means  of  gauze  strips, 
before  injection,  but  we  have  now  discontinued  doing  this,  having  found  it 
entirely  superfluous.  We  cleanse  the  opening  of  the  fistula  with  95  per  cent, 
alcohol,  press  the  nozle  of  the  charged  syringe  against  the  opening,  and, 
under  moderate  pressure,  slowly  force  a  quantity  of  the  paste  into  the  fistula 
until  the  patient  begins  to  complain  of  pressure.    The  syringe  is  then 


Fig.  6. 


removed,  and  a  pledget  of  gauze  quickly  pressed  against  the  opening,  and 
held  there  until  the  paste  has  sufficiently  set,  thus  preventing  its  escape. 
To  hasten  this  an  ice-bag  may  be  applied  to  the  region  injected.  The  patient 
remains  quiet  for  several  hours  after  the  injection. 

There  is  no  definite  rule  as  to  the  frequency  of  these  injections.  One  must 
be  guided  entirely  by  the  symptoms  wliich  follow  the  first  injection.  Cases 
discharging  pus  for  years  have  been  permanently  healed  by  one  single  in- 
jection, while  other  cases  have  required  repeated  injections,  at  intervals 
of  from  five  to  ten  days,  to  produce  a  gradual  improvement.  It  is  advisable 
to  wait  at  least  one  week  after  first  injection. 

One  rule,  however,  may  be  adhered  to;  that  is,  if  the  first  injection  of 
bismuth  paste  remains  in  the  sinus,  it  does  not  require  reinjection. 

The  manifestations  following  these  injections  are  manifold.  First  of  all, 
they  are  painless.     At  the  Home  for  Crippled  Children  in  Chicago,  where  I 


228  SIXTH   INTERNATIONAL  CONGRESS   ON   TUBERCULOSIS. 

often  injected  15  cases  in  one  ward  at  one  time,  the  children  regarded  the 
procedure  as  a  sort  of  entertainment,  and  looked  forward  to  my  semi-weekly 
visits  with  great  anticipation. 

Hemorrhage  has  not  jollowed  in  any  case.  Slight  oozing  of  blood  from 
large  granulating  surfaces  was  observed  in  a  few  cases,  usually  due  to  the 
distention  of  the  sinus,  or  from  mechanical  irritation  by  the  tip  of  the 
syringe. 

Sepsis  has  not  jollowed  in  any  case  treated  by  us,  although  we  have  fre- 
quently noted  elevation  of  temperature  following  injection.  As  a  rule,  the 
rise  would  not  be  above  103°  F.,  and  usually  subsided  in  twenty-four  to 
forty-eight  hours.  This  elevation  of  temperature  is  due  to  retention  of  pus 
in  some  recess,  or  to  a  reaction.  The  melting-point  of  the  paste  No.  2  is 
adjusted  so  that  it  will  melt  by  the  fever  heat  of  the  body,  and  in  that  way 
automatically  release  the  accumulation  of  pus.  Very  often  there  is  no 
escape  of  pus,  and  temperature  subsides  spontaneously.  Tliis  phenomenon 
will  be  explained  later,  when  the  bacteriology  of  the  bismuth  injections  is 
considered. 

Many  interesting  facts  have  been  observed  during  the  development  of  this 
method,  but  the  length  of  time  since  its  inception  does  not  warrant  us  in 
drawing  broad  and  definite  conclusions.  We  desire,  however,  to  put  on 
record  our  observations  as  we  have  noted  them. 

The  question  as  to  what  becomes  of  the  bismuth  after  injection,  we  have, 
I  believe,  solved  satisfactorily.  In  most  cases  portions  of  it  will  be  found  in 
the  dressings  within  twenty-four  hours  after  injection;  in  others,  where  the 
sinuses  are  deep  and  tortuous,  the  bismuth  paste  will  remain  in  them  for 
days  and  even  weeks,  and  frequently  it  will  heal  in  and  become  encapsulated 
and  gradually  be  absorbed. 

In  body  cavities  the  absorption  of  the  bismuth  is  preceded  by  organiza- 
tion of  the  mass  by  connective  tissue.  An  exception  to  this  has  been  noted 
by  Dr.  Joseph  C.  Beck  in  a  case  of  empyema  of  the  antrum  of  Highmore, 
when,  after  complete  healing  with  the  bismuth  method,  the  cavity  could  be 
demonstrated  by  means  of  a  probe  as  well  as  by  transillumination.  In 
cavities  with  resilient  walls,  such  as  the  pleural  cavity,  the  gradual  expan- 
sion of  the  lung  will  reoccupy  the  space  resulting  from  the  absorbing  bismuth 
paste.  This  assertion  may  be  proved,  first,  by  radiographs  taken  at  certain 
intervals;  second,  by  physical  examination  of  the  patient;  third,  by  micro- 
scopical examination  of  the  tissues. 

The  absorption  of  the  bismuth  is  well  illustrated  in  a  case  of  lung  abscess 
(Series  3,  Table  F,  Case  No.  3)  treated  and  cured  by  this  method.  Patient 
was  presented  before  the  Illinois  State  JMedical  Society  May  20,1908.  The 
three  radiographs  taken  at  definite  intervals  demonstrate  the  gradual  dis- 
appearance of  the  bismuth  from  the  chest  cavity.     Fig.  7  was  taken  after 


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Fig.  10. — Bismuth  paste  injected  into  muscle  of  guinea-pig. 


Fig.  11. — Bismuth  paste  injected  into  peritoneal  cavity  of  guinea-pij) 


PREVENTION    AND   TREATMENT   OF   TUBERCULOUS   SINUSES. — BECK.     229 

the  last  (tenth)  injection,  January  8,  1908,  and  demonstrates  that  the  cavity- 
is  nearly  obliterated  by  the  paste.  Fig.  8  was  taken  two  months  later,  and 
demonstrates  the  absorption  of  the  paste  to  one-quarter  of  its  original  size. 
Fig.  9,  taken  four  months  after  the  last  injection,  demonstrates  that  only 
small  traces  of  bismuth  paste  are  present,  and  that  the  portion  of  the  lung 
which  before  the  injection  was  dense,  due  to  the  presence  of  the  abscess,  is 
now  perfectly  clear.  The  physical  examination  of  the  patient  coincides  with 
the  findings  of  the  last  radiographs.  The  chest,  which  was  considerably 
retracted,  is  now  nearly  equal  in  size  to  the  opposite^  side,  and  perfect 
resonance  and  vesicular  breathing  are  present. 

The  response  of  living  tissues  to  the  injection  of  bismuth  paste  was 
studied  on  guinea-pigs.  The  animals  were  injected  subcutaneously,  intra- 
muscularly (Fig.  10),  and  intraperitoneally  (Fig.  11)  with  bismuth  paste,  and 
four  weeks  later  microscopical  sections  prepared. 

Postmortem  findings  showed  that  the  paste  injected  intramuscularly 
and  subcutaneously  became  encapsulated.  In  the  peritoneal  cavity  it 
was  found  loosely  embedded  in  its  recesses,  and  in  only  a  few  places  was  it 
found  adherent  to  the  peritoneum. 

Microscopical  examination  of  sections  obtained  fro^m  intramuscular  in- 
jections shows  that  the  border  of  bismuth  crystals  is  infiltrated  with  round- 
cells.  The  spaces  between  the  individual  crystals  are  closely  packed  with 
these  young  connective- tissue  cells  (Figs.  12  and  13).  The  border-line  be- 
tween the  muscle  and  bismuth  consists  of  several  strata  of  elongated  con- 
nective-tissue cells  forming  concentric  layers,  in  some  places  merging  into 
fibrous  bands  encircling  the  bismuth  plug.  Just  outside  of  this  layer  we 
find  a  large  number  of  irregularly  arranged,  shorter  and  longer,  spindle- 
shaped  cells,  which  in  places  invade  the  interstices  of  the  adjacent  muscular 
tissue. 

These  findings  demonstrate  that  when  bismuth-vaselin  paste  is  injected 
into  healthy  muscle,  it  will  be  permeated  with  fibroblasts  and  completely 
encapsulated  by  connective  tissue.  Whether  the  same  process  takes  place 
in  chronic  suppurative  cavities  after  the  bismuth  paste  has  healed  in  is  a 
matter  which  will  be  determined  as  soon  as  specimens  for  examination  can 
be  obtained.  Whatever  the  histological  findings  may  be,  the  absorption 
of  bismuth  stands  proved  by  radiographs. 

Regeneration  of  bone  in  cavities  filled  with  the  Moorhof  iodoform  plug 
has  been  proved  by  Silbermark.*  He  traces  the  progressive  development  of 
bone,  and  shows  that  it  replaces  the  gradually  disappearing  iodoform  plug. 

It  was  formerly  questioned  whether  bismuth  subnitrate  is  absorbed  in 
the  alimentary  canal,  but  it  is  now  definitely  proved  that  it  is  slowly  absorbed 
and  slowly  eliminated. 

*  Silbermark:  Deut.  Zeit.  f.  Chir.,  1904. 


230  SIXTH    INTERNATIONAL  CONGRESS   ON   TUBERCULOSIS. 

Harnack*  affirms  that  after  bismuth  administration  the  former  is  found 
in  the  liver,  spleen,  urine,  mother's  milk.  E.  S.  Wood,t  in  our  own  country, 
detected  bismuth  in  the  urine  four  weeks  after  the  last  ingestion. 

Having  ascertained  that  bismuth  is  absorbed,  even  from  dense-walled 
sinuses,  the  practical  question  arises:  Is  the  continuous  absorption  of  bis- 
muth harmful?  Although  nearly  every  physician  prescribes  bismuth  for 
digestive  disorders,  we  hear  little  of  bismuth  poisoning.  Radiographers 
give  large  quantities  by  stomach,  for  the  purpose  of  obtaining  roentgeno- 
grams of  the  digestive  organs.  Rieder  J  prepares  a  bismuth  meal,  which  con- 
tains 40  grams  of  bismuth  subnitrate,  and  states  that  he  has  noticed  no  ill 
effects  therefrom. 

In  the  literature,  however,  we  find  authentic  records  of  bismuth  poisoning. 
Professor  Kocher,§  who  used  bismuth  subnitrate  for  antiseptic  dressings 
during  surgical  operations,  reported  in  1882  several  cases  of  poisoning  which 
he  attributed  to  the  use  of  bismuth  subnitrate.  Peterson||  also  reports  a 
case  of  poisoning,  brought  about  by  rubbing  bismuth  powder  into  the  ends  of 
a  resected  joint.  A  more  recent  report  is  that  of  Dressman**  and  Muhling,tt 
of  three  cases  of  bismuth  poisoning  due  to  the  application  of  a  bismuth 
salve.  The  symptoms  noted  were  acute  stomatitis,  with  a  peculiar  black 
border  around  the  teeth,  a  dark  discoloration  of  the  mucous  membrane, 
intestinal  catarrh,  and  desquamative  nephritis.  These  reports  should  put 
us  on  our  guard,  since  they  come  from  reliable  observers. 

In  our  experience  of  more  than  two  years  with  bismuth  injections  we 
have  not  met  with  any  true  case  of  poisoning,  such  as  described  by  the 
authors  just  quoted,  although  we  have  noted  in  some  cases  where  larger 
quantities  were  injected  a  lividity  of  the  skin  and  mucous  membranes. 
In  one  case,  where  300  grams  of  a  33  per  cent,  bismuth  paste  was  injected 
into  the  pleural  cavity  and  retained  there  for  four  weeks,  we  observed  this 
lividity  and  noted  that  the  patient  lost  ten  pounds  in  weight,  had  a  small 
amount  of  albumin,  and  a  considerable  number  of  epithelial  cells  in  the 
urine.  Examination  of  blood  showed  4,416,000  red  blood-corpuscles  and 
10,000  leukocytes,  of  which  18  per  cent,  were  lymphocytes,  23  per  cent,  mono- 
nuclear leukocjrtes,  58  per  cent,  polymorphonuclear  leukocytes,  1  per  cent, 
eosinophiles,  hemoglobin  80  per  cent.  No  crystals  of  bismuth  found  in 
the  blood.  The  bismuth  paste  was  at  once  dissolved  by  injecting  heated 
olive  oil,  withdrawn  by  Bier's  suction  pump;  the  symptoms  gradually  sub- 
sided, and  the  case  progressed  favorably. 

*  Harnack:  Arzneimittellehre,  1883,  p.  383. 
t  E.  S.  Wood:  Trans.  American  Neur.  Assoc,  183,  p.  23. 
t  Archives  of  Roentgen  Ray,  No.  87,  October,  1907. 

§  Volkmann's  kiin.  Vortrage,  No.  224.  ||  Deut.  ined.  Woch.,  June  20,  1883. 

**  Munch,  med.  Woch.,  February,  1901.  ft  Munch,  mod.  Woch.,  1901. 


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PREVENTION    AND   TREATMENT   OF   TUBERCULOUS    SINUSES. — BECK.     231 

We  have  also  received  a  report  of  a  case  from  a  physician  which  bears 
all  symptoms  of  bismuth  intoxication. 

A  gentleman,  fifty-seven  years  old,  poor  in  health,  had  suffered  from 
tuberculosis  of  his  hip-joint  since  1896,  and  after  two  extensive  operations 
retained  a  fistula.  Twenty  injections  of  bismuth — a  total  quantity  of  about 
one  pound  of  bismuth  subnitrate — were  given  from  ]\Iarch  18  until  May  19, 
1908.  About  that  time  he  developed  stomatitis,  dark  discoloration  of  the 
gums,  black  border  around  the  teeth,  diarrhea,  great  thirst,  and  desquama- 
tive nephritis.  Symptoms  have,  however,  abated,  and  his  fistula  has  closed 
entirely. 

From  the  history  in  this  case  and  from  the  literature  we  must  admit 
that  there  is  a  possibility  of  intoxication  from  absorption  of  the  bismuth  in- 
jected into  sinuses  or  abscess  cavities.  We  must  not  be  deceived  by  the  fact 
that  large  doses  administered  by  stomach  will  cause  no  ill  effects.  There  is 
a  vast  difference  between  the  two  methods  of  administration.  Administered 
by  stomach,  there  is  little  chance  for  absorption,  as  it  j^asses  through  the 
alimentary  canal  in  twenty-four  hours,  and  bismuth  is  known  to  be  slowly 
absorbed.  Injected,  however,  into  the  pleural  cavity  or  psoas  abscess,  it 
is  retained  for  weeks,  and  its  absorption  may  cause  an  accumulative  effect. 

We  have,  however,  several  cases  on  record  in  which  100  grams  of  paste 
injected  into  the  cavity  remained  there  until  entirely  absorbed  without 
causing  any  symptoms  of  bismuth  intoxication.  On  the  contrar)^,  it  had  a 
veiy  salutary  effect  on  most  patients.  Nearly  all  kept  on  gaining  in  weight. 
The  same  experience  is  reported  to  us  by  surgeons  who  have  had  considerable 
experience  with  it.  Nevertheless,  we  advise  consei-vatism  in  administering 
large  doses  of  bismuth  paste  and  a  constant  watchfulness  for  symptoms  enu- 
merated. We  would  not  advise  the  injection  of  more  than  100  grams  of  the 
33  per  cent,  paste.  If  larger  quantities  are  required,  reduce  the  percentage 
of  bismuth.  This  rule  should  be  .adhered  to  at  least  until  the  possibility  of 
bismuth  intoxication  is  excluded. 

Having  ascertained  that  the  absorption  of  small  quantities  of  bismuth  is 
harmless,  we  proceed  to  the  study  of  the  factors  wliich  produce  the  rapid 
improvement  in  these  very  resistant  affections.  The  most  potent  one  ap- 
pears to  be  the  bactericidal  factor.  In  the  beginning  v/e  somewhat  under- 
estimated the  bactericidal  action  of  bismuth  subnitrate,  but  with  our 
growing  experience  we  believe  it  will  be  difficult  to  find  another  substance 
which  in  the  form  of  paste  possesses  as  many  qualities  essential  to  healing 
processes.  Its  action  is  bactericidal  and  astringent;  it  is  slowly  absorbed, 
and  in  moderate  quantities  non-toxic. 

Its  antiseptic  quality  has  been  tested  by  Professor  Kocher  and  Professor 
Peterson  in  1882.  We  have  investigated  its  bactericidal  action  by  sys- 
tematic examination  of  the  secretions  from  suppurating  sinuses  while  under 


232  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

the  bismuth  treatment,  and  have  invariably  found  a  continuous  decrease  in 
the  number  of  microorganisms,  and  in  many  cases  their  final  disappearance. 
Tubercle  bacilli  are  no  exception  to  this  rule.  This  fact  was  discovered 
in  a  case  of  tuberculous  empyema  (Case  No.  10,  Table  H,  Series  3)  in 
which  tubercle  bacilli  were  found  abundantly  in  the  pus  from  the  pleural 
cavity  previous  to  the  injection  of  bismuth.  After  the  injection  their 
number  gradually  diminished,  and  in  five  weeks  they  could  not  be  found  by 
microscopical  examination.     For  illustration  I  cite  this  interesting  case: 

B.  H.,  aged  twenty-three,  law  student,  with  negative  family  history  as  to 
tuberculosis,  developed  a  pleurisy  with  effusion  in  his  right  chest  in  January, 
1906.  In  May,  1900,  the  chest  was  aspirated  three  times  in  five  days;  each 
time  a  large  quantity  of  clear  fluid  was  withdrawn.  His  chest,  however, 
continued  to  refill  and  was  periodically  aspirated.  At  the  ninth  aspiration 
1200  c.c.  of  turbid  fluid  were  removed.  September  20,  1906,  he  went  to 
Denver,  where  his  chest  was  again  aspirated  three  times  by  Dr.  Bonney, 
who  reported  that  tubercle  bacilli  were  found  in  the  fluid  withdrawn.  On 
his  return  to  Chicago  in  November,  1906,  he  consulted  Dr.  J.  B.  Herrick, 
his  diagnosis  likewise  being  tuberculous  pleurisy  with  effusion. 

On  December  5,  1906,  an  operation  was  performed  by  Drs.  Danby, 
Hubbard,  and  Grosh,  in  Toledo,  which  consisted  in  the  resection  of  five  ribs, 
the  removal  of  a  large  amount  of  fibrinous  lymph,  and  establishment  of 
drainage.  The  large  cavity  was  irrigated  daily  with  0.5  per  cent,  of  iodin 
solution  during  his  seven  weeks'  stay  at  the  hospital,  and  thereafter  con- 
tinued at  home.  With  the  above  history,  he  was  referred  to  me  by  Dr. 
Herrick  for  the  bismuth  treatment. 

Physical  examination  revealed  a  hyperresonance  over  his  entire  right 
chest.  A  fistulous  opening  discharging  a  dark  green  pus  was  in  the  center 
of  an  eczematous  area,  about  two  inches  below  the  nipple,  internal  to  the 
axillary  line.  Smear  preparations  from  the  pus  revealed  the  presence  of 
tubercle  bacilli,  5  to  15  to  each  immersion  field,  and  a  moderate  number  of 
staphylococci. 

A  radiograph  (Fig.  14)  clearly  shows  the  size  of  the  cavity  when  empty, 
and  another  (Fig.  15)  when  injected  to  its  full  capacity  with  620  grams  of 
33  per  cent,  bismuth  paste.  The  drainage-tube  was  at  once  left  out,  and  the 
patient  allowed  to  be  outdoors.  Every  day  or  two  thereafter  the  accumula- 
tion of  pus  was  withdrawn  by  means  of  a  glass  tube  and  examined  micro- 
scopically. Each  time  we  noticed  a  diminution  in  the  number  of  tubercle 
bacilli,  and  after  eight  weeks  their  final  disappearance.  The  staphylococci 
had  likewise  disappeared.  We  also  noticed  that  the  tubercle  bacilli  which 
were  found  after  the  bismuth  had  been  injected  had  lost  their  characteristic 
shape.  They  became  granular,  beaded,  and  took  the  fuchsin  stain  more 
readily  (Figs.  19  and  20). 

Microscopical  slides  were  submitted  at  different  periods  to  Dr.  Maximilian 
Herzog  and  Dr.  A.  Gehrman,  bacteriologists,  whose  reports  coincided  with 
our  findings. 

Eight  guinea-pigs  were  injected  with  the  pus  discharged  during  the  period 
of  treatment  of  this  case.  Animal  No.  4  was  injected  April  24th  with  10 
drops  of  a  10  per  cent,  solution  of  the  pus  taken  from  the  chest  before  the 


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PREVENTION    AND   TREATMENT   OF   TUBERCULOUS   SINUSES. — BECK,     233 

bismuth  treatment  was  instituted.  Animal  developed  general  tuberculosis, 
and  died  six  weeks  later,  showing  tuberculosis  of  all  parenchymatous  organs 
and  glands. 

Animal  No.  9  was  injected  May  1st,  exactly  like  No.  4,  died  June  24th. 
Liver,  lungs  and  spleen  tuberculous. 

Animal  No.  13  injected  May  15th,  same  as  No.  4.  Elled  July  15th. 
The  report  of  fincUngs  by  Dr.  M.  Herzog  is  as  follows : 

"Post-mortem  examination  of  the  guinea-pig  No.  13,  received  alive 
July  10th,  and  killed  July  15,  1908,  showed  caseous  enlarged  axillary  lymph- 
glands  on  both  sides,  caseous  enlarged  inguinal  lymph-glands  of  the  right 
side.  Very  small  young  tubercles  in  the  liver  and  spleen.  Smears  from 
these  organs  showed  numerous  typical  tubercle  bacilli. 

"Animal  No.  16:  Baby  guinea-pig,  weighing  240  grams.  Was  injected 
June  7th  with  150  drops  of  a  10  per  cent,  solution  of  pus  from  chest  cavity. 
The  animal  has  grown  steadily,  weighing  360  grams,  and  is  very  lively,  but 
developed  two  lymph-glands  under  the  right  axilla,  which  drained  the  in- 
jected point.  One  of  the  glands  was  excised  for  examination,  and  report  of 
same  is  as  follows : 

"Sections  of  the  gland  of  G.  P.  No.  16,  stained  by  various  methods, 
show  young,  not  very  much  degenerated,  tubercles,  with  a  moderate  number 
of  tubercle  bacilli." 

To  test  the  toxicity  of  the  discharge  two  guinea-pigs  were  injected,  one 
which  had  been  infected  previously  with  tuberculous  sputum,  and  another 
perfectly  healthy  pig.  Each  received  an  injection  of  15  c.c.  of  the  discharge 
(not  diluted)  intraperitoneally,  and  both  appeared  well  for  three  days,  but 
were  found  dead  on  the  fourth  day.  Post-mortem  revealed  acute  peritoni- 
tis in  both  animals. 

Animal  No.  21  was  injected  with  10  drops  of  a  10  per  cent.  cUlution  July 
18th,  and  will  be  kept  for  further  observation. 

From  these  experiments  we  conclude  that  while  the  tubercle  bacilli 
cannot  be  detected  by  the  microscope  soon  after  the  institution  of  the  bis- 
muth treatment,  the  discharge  must  still  contain  some  bodies  to  produce 
tuberculous  disease  in  guinea-pigs,  but  the  development  of  the  disease  is 
much  slower,  and  symptoms  much  milder  in  the  animals  last  injected,  which 
proves  that  the  number  of  tubercle  bacilli,  as  well  as  their  virulence, 
diminishes  as  the  treatment  of  the  patient  progresses. 

Another  case  of  tuberculous  empyema  now  under  treatment  with  bis- 
muth paste  injection  presents  some  interesting  features  which  I  desire  to 
put  on  record: 

Mr.  W.  J.  E.,  thirty-seven  years  old;  lawyer,  with  a  family  history  free 
from  tuberculosis,  had  scarlet  fever  and  whooping-cough  in  childhood, 
measles  at  twenty,  and  angioneurotic  edema  at  thirty.  Was  always  con- 
sidered healthy. 

In  December,  1907,  he  was  attacked  with  pain  in  his  left  chest,  which 
was  diagnosed  as  pleurisy  with  effusion.  The  diagnosis  was  confirmed  when, 
on  January  29,  1908,  1500  c.c.  of  cloudy  fluid  was  withdrawn.  The  opening 
was  enlarged,  and  drainage-tube  inserted  by  physician  in  charge. 


234  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

Eight  weeks  later  the  drainage-tube  was  removed,  and  opening  allowed 
to  close.  Patient  began  to  cough,  his  temperature  rose,  whereupon  the 
drainage-tube  was  reinserted,  and  in  this  condition  he  was  sent  to  Arizona. 
He  remained  there  three  weeks,  and  although  he  gained  some  in  weight,  his 
temperature  rose  every  evening  to  102°  or  103°  F.,  his  pulse  from  100  to 
110,  cough  was  aggravated,  but  no  sputum  could  be  raised.  The  wound 
was  dressed  twice  daily  on  account  of  the  profuse  and  irritating  discharge. 

I  saw  him  first  on  June  13,  1908.  He  was  pale,  emaciated,  weighing 
130  pounds,  which  was  twenty  pounds  below  his  usual  weight.  He  com- 
plained of  weakness  and  pain  in  his  chest;  temperature  was  100^°  F.,  pulse 
105,  coughed  considerable.  The  drainage-tube  was  in  the  center  of  an  ecze- 
matous  area  in  the  axillary  line,  discharging  a  dark-green,  stringy,  tliick 
pus.  Restricted  expansion  of  his  left  chest  was  noted.  Physical  examina- 
tion of  the  right  side  of  his  chest  demonstrated  clearly  that  dulness  on  per- 
cussion, vocal  resonance,  and  fremitus  increased;  subcrepitent  rales  were 
heard  over  the  subscapular  area. 

The  tube  was  at  once  removed,  and  200  grams  of  bismuth-vaselin  in- 
jected into  the  pleural  cavity.  Radiograph  taken  (Fig.  16)  shows  the  di- 
mension of  the  cavity.  Temperature  and  pulse  became  normal  the  first 
evening. 

June  14th  to  20th:  Daily  dressing  revealed  the  pus  becoming  serous  and 
less  in  quantity.  Temperature  and  pulse  remained  normal  during  the  entire 
week;  cough  lessened;  pain  still  present;  gained  3^  pounds  in  weight. 

June  20th  to  27th:  Opening  remained  closed  all  week;  cough  ceased 
entirely;  pain  persisted;  patient  gained  2h  pounds.  By  forcing  a  cannula 
into  the  chest,  30  c.c.  of  turbid  fluid  were  removed. 

June  27th  to  July  3d:  Temperature  and  pulse  remained  normal;  gained 
2 J  pounds;  strength  and  healthy  color  returned;  pain  persisted. 

July  3d  to  19th:  Temperature  and  pulse  normal;  gained  4J  pounds;  pain 
ceased;  began  work  July  5th;  worked  nineteen  hours  one  day. 

A  systematic  examination  of  the  pus  discharge  disclosed  very  interesting 
findings,  of  which  the  report  made  by  Dr.  Maximilian  Herzog  is  here  given: 

"Specimen  1,  marked  Mr,  E,,  June  14th:  Quite  a  number  of  tubercle 
bacilli,  faintly  stained,  generally  slender  and  regular,  some  granular  and 
irregular.     Very  few  in  the  interior  of  leukocytes. 

"Specimen  2,  marked  E.,  June  15th:  Tubercle  bacilli  quite  numerous, 
two  or  three  times  as  many  as  in  specimen  No,  1,  better  and  deeper  stained, 
but  more  individuals  quite  granular  and  irregular,  some  quite  disintegrated. 
Many  in  the  interior  of  leukocytes," 

On  July  3d  another  examination  of  pus  showed  a  still  further  increase 
in  the  tubercle  bacilli  (20  to  each  immersion  field) ;  however,  nearly  all  were 
disintegrated.  On  July  11th  the  microscopical  examination  disclosed  the 
presence  of  very  few  tubercle  bacilli,  one  to  each  two  immersion  fields. 
After  July  1 1th  no  pus  could  be  withdrawn,  as  the  wound  was  entirely  healed. 

We  do  not  regard  the  gradual  diminution  in  number  of  tubercle  bacilli 
in  the  first  case,  and  the  characteristic  physical  changes  in  the  bacilli  in  both 
the  cases,  sufiicient  to  establish  a  universal  law  of  so  vast  importance.  The 
findings  are  certainly  very  significant,  in  view  of  the  fact  that  tuberculous 
sinuses  and  abscess  cavities  respond  so  promptly  to  the  bismuth  injection 


O  rt 


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PREVENTION    AND   TREATMENT   OF  TUBERCULOUS   SINUSES. — BECK.     235 

treatment.  If  the  rapid  diminution  and  disintegration  of  tubercle  bacilli 
noted  in  these  two  cases  is  not  accidental,  this  disclosure  is  certainly  of  far- 
reaching  importance.  If,  after  the  day  of  his  first  injection,  fever,  cough, 
and  sweats  disappear,  patient  regains  appetite,  sleep,  is  able  to  resume  work, 
and  continues  to  gain  weight  at  the  rate  of  2h  pounds  a  week  for  five  consecu- 
tive weeks,  as  patient  did  in  the  second  case  cited,  it  certainly  is  too  striking 
a  change  to  be  accidental. 

Whether  the  bismuth  destroys  the  bacilli  by  its  chemical  action,  or 
whether  its  presence  acts  as  a  chemotactic,  we  have  not  yet  determined, 
although  the  evidence  predominates  that  its  chemotactic  property  accounts 
for  the  destruction  of  the  microorganisms. 

Tubercle  bacilli  are  not  often  found  in  the  pus  from  tuberculous  sinuses; 
more  often,  however,  in  tuberculous  empyema.  They  lodge  in  the  granula- 
tions and  walls  of  sinuses  and  abscess  cavities  in  abundance.  The  bismuth 
paste  coming  in  contact  with  the  walls  of  the  sinuses  containing  the  bacilli, 
and  thus  inducing  chemotaxis,  has  a  destructive  action  upon  them.  This, 
to  a  certain  degree,  explains  the  interesting  microscopical  findings  of  the 
changes  and  destruction  of  the  bacilli. 

The  findings  in  the  two  cases  above  cited  suggest  the  possibility  of  apply- 
ing the  bismuth  treatment  in  tuberculous  empyema  not  as  yet  opened.  The 
opening  could  then  be  made  intentionally  for  the  introduction  of  bismuth 
for  curative  purposes. 

The  technic  of  bismuth  injections  employed  in  abscess  cavities  in  the 
chest  differs  somewhat  from  the  one  applied  in  sinuses.  In  the  chest  we 
have  to  deal  with  an  infected  cavity  which  has  a  rigid  chest-wall  on  one  side, 
and  the  retracted,  but  more  or  less  resilient  lung  on  the  other.  It  is  generally 
believed  that  if  the  air  could  be  prevented  from  rushing  into  the  cavity  with 
each  inspiration,  the  lung  would  expand  and  fill  up  the  space,  but  this  does 
not  explain  why  many  cases  do  not  heal  when  this  principle  is  carried  out 
by  the  suction  pump*  of  Perthes. 

Tuberculous  empyema  usually  results  from  tuberculous  pleurisy  with 
effusion  which  has  been  drained.  The  serous  fluid  becomes  secondarily 
infected,  and  the  cavity  keeps  on  discharging  pus  indefinitely.  The  irrigation 
with  all  sorts  of  antiseptic  washes  has  usually  retarded  the  healing.  Bier's 
suction  method,  on  the  other  hand,  has  in  many  cases  hastened  the  obliter- 
ation, partly  by  drawing  the  lung  toward  the  rigid  chest-wall,  and  partly 
by  producing  a  hyperemia  in  the  false  membrane.  Nevertheless,  a  con- 
siderable number  resist  this  form  of  treatment  also.  Our  explanation  of 
this  fact  is  that  as  long  as  the  walls  which  line  the  pleural  cavity  are  the 
seat  of  living  tubercle  bacilli,  we  cannot  expect  obliteration  of  the  space. 
The  cavity  must  first  be  disinfected  before  healing  be  produced.  Our  method 
*  Perthes:  Mitteilungen  a.  d.  Grenzgcb.  d.  Med.  u.  Chir.,  Bd.  vii,  Heft  4,  5. 


236  SIXTH   INTERNATIONAL    CONGRESS   ON  TUBERCULOSIS. 

of  dealing  with  these  cases,  I  beUeve,  possesses  the  means  which  are  essential 
to  the  obliteration.  It  produces  pressure,  steriUzes  the  cavity,  and  stimulates 
healthy  granulations.  The  microscopical  findings  of  secretions  and  the  results 
of  treatment  bear  out  this  statement. 

After  a  radiograph  of  the  empty  cavity  has  been  taken  and  an  examina- 
tion of  the  secretion  has  been  made,  the  cavity  is  injected  with  100  grams  of 
bismuth  paste,  formula  No.  1.  The  drainage  is  at  once  chscontinued,  and 
the  opening  allowed  to  close.  Should  temperature  rise  above  101°  F.  after 
twenty-four  hours,  or  the  patient  complain  of  severe  pressure,  the  accumu- 
lated fluid  should  be  drained  off  and  the  opening  again  allowed  to  close. 
If  the  temperature  remains  normal  and  no  unpleasant  symptoms  arise,  the 
100  grams  of  paste  injected  may  be  left  in  for  absorption,  providing  no  signs 
of  bismuth  intoxication  arise.  Repetition  of  the  injection  is  necessary  only 
when  the  bismuth  paste  is  discharged  with  the  pus,  and  microorganisms 
are  still  found  in  the  secretions.  In  our  early  experience  we  believed  that 
the  cavity  had  to  be  overdistended  with  the  paste  in  order  to  produce  heal- 
ing, and  we  introduced  as  much  as  the  cavity  would  hold.  (See  Fig.  15.) 
Such  large  quantities  are  not  only  unnecessary,  but  also  liable  to  produce 
bismuth  intoxication.  Should  any  signs  of  this  poisoning  appear,  the 
bismuth  must  at  once  be  withdrawn  by  means  of  a  suction  pump  after  it 
has  been  dissolved  by  warm  olive  oil.  After  this  the  Bier  suction  pump  is 
very  valuable  in  producing  a  vacuum  in  the  cavity  and  drawing  the  lung 
toward  the  chest-wall,  which  in  its  sterile  condition  will  readily  close. 

We  have  thus  far  applied  this  method  only  in  cases  of  empyema  and  lung 
abscess  where  drainage  has  long  been  established  by  operation  and  second- 
ary infection  was  present,  but  its  judicious  application  to  tuberculous  pleurisy 
seems  reasonable.  Tuberculous  pleurisy  is,  in  the  majority  of  cases,  either 
a  forerunner  of  tuberculosis  of  the  lung  or  a  complication  of  this  disease. 
This  has  been  noted  by  most  observers.  In  450  cases  of  tuberculosis  treated 
at  the  Stony  Wold  Sanatorium  (Goodall*),  45  per  cent,  suffered  from  pleurisy 
during  their  residence  at  the  sanatorium.  In  371  autopsies  on  tuberculous 
patients,  279  cases  (more  than  75  per  cent.)  were  found  to  have  pleuritic 
adhesions  (Banksf). 

The  effusion  appears  to  have  a  beneficial  effect  upon  the  disease  process, 
and  its  entire  withdrawal  is  undesirable  (Opie|),  since  the  tapping  often 
leads  to  the  purulent  form,  but  aside  from  this  it  may  help  to  disseminate 
the  tubercle  bacilli  by  friction  of  the  pleural  surfaces  (Pinquet§).  Any  form 
of  treatment  which  will  destroy  the  tubercle  bacilli  in  the  pleural  cavity 
before  they  have  invaded  neighboring  structures,  namely,  the  lung  and 

*  Goodall:  Medical  Record,  June  27,  1908,  p.  1074. 

t  Banks:  Annual  Report,  Supervising  Surgeon,  Gen.  Marine  Hosp.  Serv.,  1901. 

i  Opie:  Experimental  Pleurisy,  Jour.  Ex.  Med.,  vol.  ix.  No.  4,  1907. 

§  Pinquet:  These  de  Lyon,  1899. 


PREVENTION    AND   TREATMENT   OF   TUBERCULOUS   SINUSES. — BECK.     237 

mediastinum,  will  certainly  be  welcome,  and  this  remedy,  I  believe,  lies  in 
the  introduction  of  a  small  quantity  of  the  bismuth  paste  into  the  pleural 
cavity  as  soon  as  the  diagnosis  of  tuberculous  pleurisy  is  ascertained. 

The  mechanical  action  of  the  bismuth  paste  is  a  prominent  factor  in  the 
heahng  process.  By  filling  the  sinuses  with  a  semisoUd  paste  we  separate 
the  diseased  walls,  bringing  them  in  contact  with  a  substance  in  itself  bac- 
tericidal and  stimulating,  slowly  absorbing,  and  oily.  The  uniform  pressure 
thereby  exerted  on  all  parts  of  the  tracts  is  a  desirable  condition  to  promote 
healing.  Pressure  has  a  great  therapeutical  value.  Nature  produces  pres- 
sure in  the  healing  processes  of  inflammation.  The  infiltration  of  tissues 
and  the  accumulation  of  fluids  in  inflamed  joints  are  examples  of  pressure 
produced  by  nature  for  healing  purposes.  Professor  Bier's  hyperemia 
treatment  likewise  indicates  that  pressure  is  a  factor  favorable  to  the  proc- 
ess of  heaUng. 

Another  factor,  not  entirely  to  be  ignored,  is  the  action  of  the  a;-rays 
upon  tuberculous  disease  in  the  presence  of  bismuth-vaseUn.  Literature 
contains  so  many  contributions  from  reliable  sources  on  the  action  of  the 
a;-ray  upon  tuberculous  disease  that  it  deserves  due  consideration  in  connec- 
tion with  the  treatment  of  tuberculous  sinuses.  Gibson  claims  that  the 
a;-ray  leads  to  the  destruction  of  tubercle  bacilli  in  the  body,  thereby  affecting 
the  tuberculo-opsonic  index.  McCuUough  has  confirmed  this  fact  by  ex- 
tensive experiments  upon  tuberculous  patients,  and  the  same  views  are  sup- 
ported by  Wilkinson  in  his  experiments  with  and  treatment  of  leprosy.  Since 
both  bismuth  and  vaselin  are  radio-active  substances,  and  since  all  our 
cases  have  been  exposed  to  the  x-ray  at  least  once  after  injection  for  the 
purpose  of  obtaining  radiographs,  we  are  led  to  inquire  how  much  the  ex- 
posure to  the  x-ray  adds  to  the  acceleration  of  the  healing  process.  It  must 
be  admitted  that  it  can  play  only  a  secondary  part  in  the  healing,  since  some 
of  our  noted  surgeons  have  obtained  very  good  results  without  the  aid  of 
the  x-ray.  We  have  noted,  however,  that  in  resistant  cases,  especially  those 
where  external  erosions  existed,  daily  exposure  to  the  x-ray  for  two  minutes 
stimulated  the  healing  process.  We  do  not  recommend  it  as  a  routine 
treatment,  but  resei-ve  its  use  to  the  more  resistant  cases  with  erosions. 

The  study  of  the  various  secretions  and  excretions  of  the  body,  as  well 
as  the  chemical,  cytotical,  and  opsonic  changes  in  the  blood,  as  affected  by 
the  bismuth  injections,  is  still  open  to  investigation. 

Limitations. 
While  the  method  of  bismuth  injections  has  a  large  field  for  application, 
there  are  certain  Hmitations  to  its  use.     In  biliary  and  pancreatic  fistulas, 
also  sinuses  communicating  with  the  cranial  cavity,  this  treatment  is,  for 
obvious  reasons,  dangerous. 


238  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

Although  we  have  thus  far  encountered  no  serious  compUcations  after 
the  injection  of  bismuth  paste,  accidents  are  possible.  The  bismuth  plug 
may,  by  pressure  on  a  vital  organ,  produce  unpleasant  symptoms.  It  is 
also  possible  that,  by  overdistention  of  a  newly  formed  abscess  cavity,  its 
walls  may  be  ru^Dtured  and  a  new  area  infected.  Neighboring  large  veins 
may  be  so  altered  by  the  suppurative  process  as  to  permit  the  injection  to 
break  through  the  thin  and  diseased  wall,  and  in  this  way  enter  the  circula- 
tion, causing  serious  consequences. 

Here  I  desire  to  put  on  record  a  fatal  case,  with  post-mortem  findings,  and 
presentation  of  lung  specimen,  reported  to  me  by  a  physician  from  one  of 
the  western  cities: 

Case  R. — Three  years  ago  the  patient  sustained  a  facture  of  the  second 
sacral  vertebra,  resulting  in  a  loss  of  motion  and  sensation  below  the  hips, 
loss  of  control  of  bladder  and  rectum. 

A  fistulous  tract  leading  from  an  area  of  broken  integument  established 
itself  two  and  one-half  years  ago,  and  has  persisted  in  spite  of  treatment  at 
different  times  with  silver  nitrate  solution  and  peroxid  of  hydrogen.  The 
fistula,  which  had  its  opening  in  the  middle  line  over  the  third  sacral  and 
extended  upward  and  to  the  left  of  the  median  line  for  about  six  inches,  was 
cureted  three  times  during  the  course  of  treatment. 

On  May  2,  1908,  9  a.  m.,  an  injection  of  two  ounces  of  freshly  prepared 
paste  was  made.  Ten  minutes  following  the  injection  the  patient  com- 
plained of  pain  in  the  chest,  and  began  perspiring  freely.  At  first  the  patient 
became  quite  blanched,  but  soon  showed  cyanosis,  which  continued  until 
his  death,  eighteen  hours  later.  The  temperature  was  normal,  and  pulse 
varied  between  90  and  130.  The  cyanosis  deepened  after  about  twelve 
hours,  and  the  patient  would  no  longer  respond  to  respiratory  and  cardiac 
stimulants.     The  patient  died  in  coma  eighteen  hours  after  the  injection. 

Post-mortem  showed  the  venous  capillaries  of  the  lungs  filled  with  bis- 
muth paste. 

Microscopical  examinations  of  specimens  were  made  by  Dr.  M.  Herzog, 
whose  report  is  as  follows: 

The  small  pieces  of  pulmonary  tissue  received  look  congested.  The 
cut  surface  presents  to  the  naked  eye  some  white  masses  not  much  larger 
than  the  point  of  a  pin.  The  material,  after  having  been  embedded  in  paraf- 
fin, was  sectioned  and  stained  with  hematoxyhn  and  eosin  and  with  carbol- 
fuchsin  for  the  detection  of  tubercle  baciUi. 

Since  the  examination  showed  that  the  white  masses  noticed  are  com- 
posed of  subnitrate  of  bismuth,  and  since  it  was  necessary  to  distinguish 
beyond  mistake  between  the  bismuth  salt  and  the  coal-dust,  freely  present 
in  the  pulmonary  tissue,  sections  of  the  latter  were  treated  for  five  minutes 
in  a  hot  20  per  cent,  watery  solution  of  HNO,  which  dissolved  out  the  bis- 
muth salt,  but  left  the  coal-dust  unchanged. 

Result  of  the  Microscopical  Examination. — The  pulmonary  tissue  shows 
generally  open  alveoli;  however,  some  refilled  with  an  edematous  exudate. 
The  interalveolar  septa  appear  partly  normal,  partly  widened  by  infiltrating 
mononuclear  cells.    The  interalveolar  capillaries  here  and  there  are  markedly 


PREVENTION   AND   TREATMENT   OF   TUBERCULOUS   SINUSES. — BECK.    239 

congested,  as  are  a  number  of  larger  venules  and  arterioles.  The  congestion 
is  perhaps  best  marked  in  the  subpleural  tissue.  The  pleura  itself  is  incon- 
siderably thickened;  the  whole  pulmonary  tissue  presents  a  marked  con- 
dition of  anthracosis.  Cells  filled  with  coal-dust  are  seen  in  the  alveolar 
spaces,  and  more  solid  masses  of  coal-dust  are  found  around  the  broncliioles 
and  in  the  neighborhood  of  the  peribronchial  tissue. 

The  larger  bronchioles  are  densely  filled  with  bismuth  subnitrate  crystals. 
These  do  not  seem  to  have  been  veiy  long  in  this  location,  because  there  is 
no  tissue  reaction  around  the  plugs  of  bismuth  crystals.  There  is  no  evi- 
dence of  any  absorption  of  the  bismuth. 

The  pulmonary  tissue  nowhere  shows  any  distinct  tubercles;  however, 
nodules  composed  of  round-cells,  carbon-loaded  cells,  and  extravasated 
red  blood-corpuscles  are  seen. 

No  tubercle  bacilli  were  discovered  in  these  nodules. 

By  animal  experiments  we  have  demonstrated  that  the  bismuth  paste 
injected  into  the  axilla  caused  death  within  two  minutes,  due  to  the  en- 
trance of  the  paste  into  the  axillary  vein,  and  finally  blocking  of  the  branches 
of  the  pulmonary  artery.  Symptoms  were  a  sudden  cyanosis,  short  gasp- 
ing breathing,  and  convulsions. 

Enthusiasts  may  be  tempted  to  daring  procedures,  encouraged  by  the 
surprising  results  they  have  obtained  in  cases  previously  regarded  as  hope- 
less, and  carry  the  treatment  beyond  the  line  of  safety.  We  desire,  there- 
fore, to  caution  them  against  bold  procedures  in  testing  the  method.  We 
recommend  its  gradual  conservative  development.  In  large  cities,  where 
clinical  material  is  abundant  and  many  paupers  treated,  the  physician  may 
be  tempted  to  place  this  treatment  into  the  hands  of  the  laity,  believing  it 
to  be  simple  of  apphcation.  Such  a  procedure  is  to  be  condemned.  The 
treatment  is  best  carried  out  in  well-equipped  hospitals,  where  the  patient 
may  be  observed  and  treatment  carried  out  scientifically. 

Tuberculous  conditions  thus  far  treated  with  bismuth  paste  have  been 
mainly  sinuses  originating  in  tuberculous  osteomyelitis  and  arthritis;  sinuses 
following  extirpation  of  tuberculous  kidney  and  lymphatic  glands,  rectal 
fistulas,  and  cavities  following  tuberculous  empyema  or  lung  abscess. 

The  injection  was  tried  in  a  case  of  tuberculous  ankle-joint,  but  owing 
to  the  great  destruction  of  bones,  the  joint  finally  had  to  be  opened,  the 
sequestra  removed,  and  then  the  remaining  cavity  filled  with  the  bismuth 
paste,  after  which  it  promptly  healed.    The  history  of  this  case  is  as  follows: 

G.  P.,  girl,  five  years  old,  family  history  negative,  was  well  the  first  year 
of  her  life,  when  a  swelling  was  noticed  al^out  her  left  ankle-joint.  This  was 
treated  locally,  and  five  months  later  an  abscess  was  incised  above  the  in- 
ternal malleolus.  September,  1907,  a  new  swelling  appeared  at  the  ankle- 
joint.  An  injection  into  the  joint,  with  an  aspirating  syringe,  of  one  ounce 
of  a  33  per  cent,  bivaselin  paste  in  liquid  state,  resulted  in  a  rise  of  tempera- 
ture to  102°  F.;  pulse,  130,  which  gradually  subsided. 


240  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

Radiographs  then  taken  disclosed  that  the  bismuth  not  only  reached  all 
parts  of  the  joint,  but  also  entered  the  lower  end  of  the  tibia,  where  the 
sequestrum  was  lodged  (Figs.  17  and  18). 

A  second  injection  was  made  three  weeks  later,  and  this  resulted  in  a 
temperature  of  104°  F.,  pulse  145,  and  again  a  gradual  remission  to  normal. 
It  was  then  decided  to  remove  all  sequestra,  which  was  done  on  the  seventh 
of  March,  1908,  and  a  sinus  resulted.  This  sinus  was  then  treated  by  the 
bismuth  injections  and  healed  out  within  seven  weeks. 

This  case  illustrates  that  when  caries  of  bone  is  present  in  a  closed  cavity, 
all  sequestra  should  first  be  thoroughly  removed,  and  at  once  filled  up  with 
liquefied  bismuth-vaselin  paste.  Any  attempt  to  close  the  external  wound 
is  unnecessary  and  even  detrimental,  since  it  prevents  the  escape  of  secretions 
alongside  of  the  paste.  Where  sequestra  are  present  and  sinus  already  exists, 
the  injections  should  be  tried  for  a  reasonable  length  of  time  before  an 
operation  is  advised.  I  have  at  least  two  cases  on  record  where  sequestra 
were  clearly  demonstrated  by  radiographs  and  healed  under  the  bismuth 
paste  treatment. 

Whether  the  injection  of  bismuth  into  tuberculous  joints  where  the  de- 
struction of  bone  is  slight  or  confined  to  the  synovia  is  preferable  to  that  of 
iodoform-glycerin,  must  be  determined  by  actual  trial. 

Prevention  of  Sinuses. 

The  most  important  advance  recently  made  by  us  is  the  prevention  of 
tuberculous  sinuses.  We  have,  I  believe,  satisfactorily  demonstrated  that 
tuberculous  sinuses  can  also  be  prevented  by  the  injection  of  a  bismuth  paste. 

This  method  is  as  follows:  A  cold  abscess  following  tuberculous  disease 
should,  under  most  aseptic  measures,  be  opened  by  an  incision  about  |  of 
an  inch  in  length,  the  pus  evacuated,  and  the  cavity  refilled  at  once  with 
100  to  300  grams  of  a  10  per  cent,  bismuth-vaselin  paste,  opening  not  sealed, 
nor  drainage  inserted.  A  sterile  gauze  dressing  is  placed  over  the  incision, 
and  a  five-yard  sterile  gauze  bandage  is  snugly  put  on  and  securely  pinned, 
60  that  the  patient,  usually  a  child,  cannot  displace  and  so  infect  it.  Dress- 
ings are  to  be  changed  daily  under  perfect  aseptic  measures.  Should  the 
opening  close  and  fluid  reaccumulate,  it  may  be  reopened,  the  fluid,  which  is 
then  more  serous,  pressed  out,  but  the  injection  need  not  be  repeated.  This 
method,  properly  carried  out,  will  prevent  secondary  infection. 

Incision  and  drainage  of  a  non-febrile  tuberculous  abscess  was  heretofore 
considered  a  blunder,  since  it  nearly  always  resulted  in  secondary  infection. 
By  our  method  tlie  secondary  infection  is  prevented  mechanically,  i.  e., 
the  injected  abscess  cavity  contracts,  forcing  a  small  quantity  of  the  thick 
paste  from  within  through  the  small  incision,  thereby  blocking  the  opening 
and  preventing  the  entrance  of  infectious  material.     Four  cases  have  thus 


Fig.  IS. — Second  injection  of  bismuth  paste  into  tuberculous  ankle-joint.      Case   15, 

see  Fig.  17. 


Figs.  I'.l  anil  '_'().      I'hotoinicrojjraphs  of  disintegrated  tui)en-ular  bacilli. 


PREVENTION    AND   TREATMENT   OF   TUBERCULOUS    SINUSES. — BECK.     241 

far  been  treated  by  us  with  this  method,  and  three  terminated  favorably, 
the  fourth,  only  recently  injected,  is  still  under  treatment,  progressing 
favorably.  The  first  trial  of  this  prophylactic  method  was  made  by  me 
January  17,  at  the  North  Chicago  Hospital,  on  a  two  and  one-half -year-old 
boy,  who  had  a  tuberculous  abscess  about  the  middle  of  the  tibia.  The 
method  described  above  was  employed  and  proved  successful,  the  cavity 
having  closed  in  one  week. 

A  second  case  was  treated  in  this  manner  by  my  brother,  Dr.  Joseph  C. 
Beck,  a  week  later,  when  he  obtained  a  similar  result  by  injecting  an  abscess 
over  the  left  orbit  of  a  child  suffering  from  tuberculous  osteomyehtis  of 
the  frontal  bone. 

In  the  third  case  (Series  2,  Table  C,  Case  1),  a  boy  four  and  one-half 
years  old  with  a  large  psoas  abscess  resulting  from  tuberculous  spondylitis, 
the  abscess  was  incised  by  me  at  the  Home  for  Crippled  Children,  Chicago, 
April  10,  1908,  in  the  manner  above  described.  A  quart  of  debris  was 
evacuated,  and  the  cavity  injected  with  120  grams  of  a  10  per  cent,  bismuth- 
vaselin  paste  in  Hquid  state.  The  necessary  precautions  against  infection 
were  taken,  and  the  temperature  has  remained  absolutely  normal  up  to  this 
day,  whereas  it  rose  from  99°  to  100°  F.  before  the  abscess  was  evacuated 
and  injected  with  bismuth  paste.  The  incision  closed  in  four  days,  was  in- 
tentionally reopened  three  days  later,  and  about  three  ounces  of  a  muddy 
liquid,  serous  in  character,  was  squeezed  out,  and  60  grams  of  33  per  cent, 
bismuth  injected.  The  opening  closed  three  days  later,  has  remained  so, 
and  to  this  date,  July  20th,  has  not  refilled. 

I  am  under  great  obligations  to  the  medical  profession  for  reports  of  cases 
treated,  which  will  enable  me  to  give  a  comprehensive  summary  as  to  the 
value  of  this  method. 

I  wish  also  to  emphasize  the  fact  that  the  presentation  of  this  method  of 
diagnosis,  prevention,  and  treatment  of  fistulous  tracts  and  abscesses  is  not 
intended  to  displace  all  other  good  methods  now  in  vogue,  such  as  Bier's 
hyperemia,  fresh  air,  vaccine  treatment,  etc.  All  we  ask  is  that  our  method 
be  fully  tested,  and  if  found  satisfactory,  then  only  to  be  given  its  proper 
place  in  the  treatment  and  prevention  of  tuberculous  sinuses  and  abscess 
cavities. 

The  collective  report  of  cases  treated  by  this  method,  and  obtained  from 
surgeons  of  various  hospitals  in  this  country,  is  as  follows: 

The  total  number  of  cases  treated  is  192,  of  which  143  were  tuberculous, 
23  non-tuberculous,  and  26  doubtful.  Of  these  cases,  123,  or  64  per  cent., 
are  healed  at  the  present  time;  55  cases,  or  28^  per  cent.,  are  improved  and 
still  under  treatment;  11,  or  6  per  cent.,  are  unchanged;  and  3,  or  1^  per  cent., 
died  during  the  period  of  treatment  or  after.  The  varieties  of  affections 
treated  and  the  results  obtained  are  here  tabulated.     Fourteen  of  these  cases 


242 


SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 


were  treated  prior  to  my  first  publication,  January  15,  1908,  and  of  these 
13  cases  are  now  entirely  healed,  1  hopeless  case  remaining.  The  remainder 
of  178  cases  were  treated  during  the  period  of  the  last  eight  months. 


SUMMARY  REPORT  OF  192  CASES  TREATED  BY  BISMUTH  PASTE  METHOD. 


Tuberculous  spondylitis  with   sinuses 

"  hip-joint  with  sinuses 

"  sacrum     and     iliac     syn- 

chondrosis with  sinuses 
"  knee-joint  with  sinuses . .  . 

"  ankle-joint  with  sinuses . . 

"  wrist-joint  and     fingers 

with  sinuses 

Osteomyelitis  of  femur  with  sinuses . .  . 
"  tibia  with  sinuses. ..  . 

"  humerus  with  sinuses 

"  ulna  with  sinuses 

Tuberculosis  of  fascia  and  muscle  with 

sinuses 

Empyema  and  tuberculous  lung  ab- 
scess   

Tuberculosis  of  ribs  with  sinuses 

Suppurative  sinuses  of  head 

Sinuses  following  tuberculous  glands . . 

Osteomyelitis  mandibulce 

Sinuses    following    abdominal    opera- 
tions   

Rectal  fistulae 

Tuberculosis  of  kidney  with  sinuses .  .  . 


W  B 


26 
43 

7 
5 
4 

4 
12 
4 
3 
2 


19 
6 
6 
6 
1 

16 

18 
7 


192 


Hb\led. 


13 
21 

7 
4 
3 

4 
6 


14 
4 
3 
4 
1 

13 

13 

5 


123 

or 
64  per 
cent. 


Improved. 


9 
19 


55 

or 

28^  per 

cent. 


Un- 
changed. 


11 

or 

6  per 

cent. 


Died. 


3 
or 
IJ  per 
cent. 


Conclusions. 

1.  A  successful  surgical  operation  for  tuberculous  sinuses  or  fistulas 
depends  principally  upon  an  exact  knowledge  of  the  extent,  direction,  and 
number  of  sinuses  before  the  operation  is  undertaken. 

2.  Radiographs  obtained  by  previously  injecting  the  sinus  with  a  bis- 
muth paste  show  distinctly  the  origin  and  extent  of  sinuses.  Such  radio- 
graphs should  always  be  taken  before  an  operation  is  decided  upon. 

3.  Tuberculous  sinuses,  fistulous  tracts,  abscess  cavities,  including  em- 
pyema, can  be  cured  by  injecting  them  with  a  33  per  cent.  bismuth-vaseUn 
paste,  and  in  most  cases  surgical  operation  becomes  unnecessary. 


PREVENTION    AND   TREATMENT   OF   TUBERCULOUS   SINUSES. — BECK.     243 

4.  The  formation  of  sinuses  and  fistulous  tracts  may  be  prevented  by- 
opening  cold  abscesses,  evacuating  the  fluid,  and  at  once  injecting  a  quantity 
(not  exceeding  300  grams)  of  10  per  cent,  bismuth-vaselin  paste,  and  not 
seaUng  the  opening. 

5.  When  sequestra  are  present,  the  injections  should  be  tried  for  a  rea- 
sonable length  of  time,  and  risky  operations  should  be  reserved  as  a  last 
resort. 

6.  Bismuth  subnitrate  is  a  bactericidal,  chemotactic  substance,  which  is 
slowly  absorbed  and  slowly  eliminated.  Injections  up  to  100  grams  of  the 
33  per  cent,  paste  produce  no  toxic  effect.  In  large  doses  it  may  produce 
symptoms  of  intoxication,  such  as  ulcerative  stomatitis,  black  border  of 
gums,  diarrhea,  cyanosis,  desquamative  nephritis,  and  loss  of  weight. 

7.  While  these  injections  are  effective  in  all  suppurative  sinuses  and 
cavities,  those  of  tuberculous  origin  respond  to  them  more  readily. 

8.  The  secretions  from  sinuses  change  their  character  after  the  injection, 
becoming  seropurulent  or  serous,  and  microorganisms  gradually  diminish 
and  often  disappear.     Tubercle  bacilli  are  no  exception. 

9.  This  method  of  treatment  is  applicable  to  the  suppurative  accessory 
sinuses  of  the  head. 

10.  That  patients  regain  their  general  health,  gain  rapidly  in  weight  after 
the  sinuses  are  closed. 


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Present  Conditions. 

Much  improved.  Fourteen  se- 
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Improved. 

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Number  op 
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7  injections. 

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Osteomyelitis  of  femur. 
Spondylitis  (tub.). 
Osteomyelitis  left  tibia. 

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16    years. 
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249 


250  SIXTH   INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

Traitement  chirurgical  des  sinus  tuberculeux. — (Beck.) 

Diagnostic. — Le  succes  du  traitement  chirurgical  des  sinus  tuberculeux 
depend  de  la  correction  du  diagnostic  anatomique.  Les  frontieres  et 
toutes  les  ramifications  peuvent  etre  clairement  indiquees  par  des  radio- 
graphes  obtenus  de  cette  maniere:  on  injecte  dans  la  fistule  une  pate  de 
bismuth- vaselin  a  33  pour  100  qui  a  ete  liquefiee  a  la  chaleur  et  qui  se 
solidifie  rapidement  apres  injection. 

Traitement. — L 'injection  de  pate  de  bismuth-vaselin  a  paru  plus  efficace 
encore  pour  gu6rir  les  sinus  et  les  abces  tuberculeux,  y  compris  I'empyeme 
de  la  plevre.  Dans  certains  cas  qui  s'etaient  montres  longtemps  r^fractaires 
au  meilleur  traitement  medical  et  chirurgical,  la  suppuration  a  cess6  et  la 
guerison  s'est  produite  en  quelques  semaines.  Quand  un  sequestre  est  le 
foyer  de  la  maladie,  it  faut  ordinairement  I'enlever.  Le  sousnitrate  de 
bismuth  est  une  chose  excellente  pour  ce  genre  de  traitement,  car  il  est 
bactericide,  s'absorbe  lentement  et  n'a  pratiquement  pas  de  proprietes 
toxiques. 

Prophylaxie. — On  pent  empecher  les  traits  fistuleux  en  ouvrant  I'abces 
froid  par  une  incision  de  trois  quarts  de  centimetre:  on  fait  ^vacuer  le  pus 
et  on  remplit  imm6diatement  la  cavite  de  I'abces  avec  une  pate  de  bismuth- 
vaselin  a  10  pour  100,  sans  fermer  I'ouverture.  .  Cela  empeche  une  infection 
secondaire  qui  contre-indiquait  jadis  I'incision  des  abces  tuberculeux. 

Rapport  collectif  des  cas  traites  de  cette  maniere,  depuis  cinq  mois,  dans 
les  hopitaux  g^neraux,  les  hopitaux  militaires  et  maritimes  des  Etats-Unis, 
et  par  les  praticiens. 


Tent  life  for  the  tuberculous  patients. 


One  of  the  wards. 


HOW  THE   STATE   OF   MINNESOTA   CARES    FOR   ITS 
INDIGENT  CHILDREN  SUFFERING  FROM  TUBER- 
CULOSIS OF  THE  BONES  AND  JOINTS. 

By  Arthur  J.  Gillette,  M.D., 

Surgeon-in-Charge  of  the  Minnesota  State  Hospital  for  Indigent  Crippled  and  Deformed  Children, 

St.  Paul,  Minnesota. 


What  mental  anguish  mothers  would  be  spared  if  they  only  knew  how 
rare  it  is  for  a  child  to  be  born  a  cripple,  and  when  it  does  occur,  with  a  very 
very  few  exceptions,  how  easily  they  are  cured.  Of  what  a  terror  they  would 
be  relieved  if  they  knew  that  mental  impressions  have  nothing  whatever  to 
do  with  the  deformities  and  birth-marks  which  do  exist.  Injuries,  too, 
seldom  result  in  deformities.  Even  physicians  do  not  realize  that  most 
deformities  are  the  result  of  disease  developed  during  infancy  and  childhood. 
The  disease  in  most  instances  is  tuberculosis  of  the  bones  and  joints.  There 
are  deformities  acquired  by  other  diseases,  but  tuberculosis  directly  or  in- 
directly causes  more  than  half. 

By  what  channel  the  bacillus  of  tuberculosis  enters  the  bones  and  joints 
is  not  the  concern  of  this  paper,  but  chiefly  its  contagiousness,  and  the 
necessity  of  a  State  institution  to  care  for  those  children  whose  parents  are 
not  able  to  give  them  the  proper  food  and  clothing,  house  them  properly,  or 
furnish  mechanical  appliance,  or  a  surgeon.  As  long  as  the  disease  is  con- 
fined to  the  bone  or  joint  and  there  are  no  discharging  abscesses,  it  is  not 
contagious.  There  are  authorities  who  claim  that  tuberculosis  of  a  bone  or 
joint  is  always  secondary;  that  the  primary  lesion  is  either  in  the  lungs,  the 
pleura,  the  glands,  the  nose,  the  throat,  the  ears,  the  intestinal  or  urinary  tract. 
We  have  not  always  been  able  to  find  lesions  elsewhere  than  in  the  bones 
and  joints  in  our  cases,  but  in  most  cases  we  do,  and  it  probably  precedes 
the  bony  involvement.  It  is  hard  to  estimate  from  statistics  just  what 
proportion  of  tuberculosis  of  the  bones  and  joints  have  abscesses. 

Tuberculous  abscesses  are  very  erratic,  to  say  the  least.  They  come  on 
iasidiously,  and  sometimes  disappear  the  same  way.  They  may  appear  as 
an  early  symptom.  They  may  show  themselves  at  a  stage  in  the  treatment 
when  all  is  progressing  most  favorably.  They  sometimes  appear  when  all 
the  symptoms  have  disappeared  and  the  child  is  walking  about. 

Cases  which  are  properly  handled  from  the  onset  of  the  disease  may  sup- 

251 


252  SIXTH   INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

purate;  neglected  cases  are  more  likely  to  do  so.  The  children  of  the  poor 
must  of  necessity  be  neglected,  either  thi'ough  indifference  or  want  of  means. 
Undoubtedl}^  every  discharging  sinus  from  a  tuberculous  lesion  contains  the 
bacillus  of  tuberculosis,  even  though  we  are  not  always  able  to  demonstrate 
it.  These  openings  leading  to  the  joint  remain  patent  for  so  long  that 
they  soon  contain  many  other  bacteria  and  pus-forming  microorganisms,  as 
well  as  the  bacilli  of  tuberculosis.  We  have  had  them  with  a  most  viru- 
lent form  of  diphtheria  in  the  sinuses  leading  from  the  tuberculous  abscesses. 

Children  have  been  brought  to  our  hospital  with  running  sores,  who, 
with  the  aid  of  crutches,  were  attending  public  school;  their  clothes  in  the 
region  of  the  abscess  saturated  with  its  discharge;  not  even  the  crudest  kind 
of  a  surgical  dressing  applied.  Not  all  children  with  tuberculosis  in  the 
bones  and  joints  are  in  danger  of  communicating  the  disease  to  others. 
Far  from  it.  All  children  who  have  tuberculosis  of  the  bones  should  be 
examined  for  abscesses  and  for  other  sources  from  which  the  disease  might 
be  contagious,  at  least  before  attending  school.  Usually  these  children, 
however,  are  too  ill  to  attend  school,  and  it  is  in  their  own  home  where  the 
danger  lies,  for  we  are  dealing  with  people  whose  homes  are  very  likely  to 
be  poorly  ventilated.  Even  if  we  could  instruct  them  as  to  ventilation,  it 
would  be  impossible  for  them  to  carry  out  the  instructions.  As  to  nour- 
ishment, it  is  impossible  for  them  to  obtain  the  proper  food,  and  should  it 
be  furnished,  often  they  do  not  know  how  to  prepare  it. 

If  you  wish  to  isolate  the  patient,  in  cases  of  discharging  abscesses,  or 
when  they  are  complicated  by  lung  involvement,  even  if  they  are  made  to 
appreciate  its  importance,  they  are  unable  to  follow  the  instructions.  In 
order  to  dress  these  abscesses  they  must  have  the  means  to  purchase  mate- 
rial for  surgical  dressings.  Three  years  would  probably  be  a  fair  estimate 
of  the  time  it  takes  to  cure  these  cases.  Therefore  the  parents  or  relatives 
become  indifferent  to  warnings,  forget  the  dangers,  and  become  careless,  for 
their  idea  of  a  cure  is  when  the  pain  is  relieved.  They  pay  little  attention 
to  the  abscesses  as  long  as  the  child  can  run  about  and  play. 

We  have  hoped  much  that  the  .r-rays  would  locate  for  us  the  first  foci 
of  the  disease,  and  we  would  be  able  to  remove  it  and  thus  shorten  the  period 
of  treatment.  With  this  we  have  been  more  or  less  disappointed.  The 
congestive  treatment,  the  iodoform  injections,  and  other  chemicals  help 
some. 

We  have  established  no  hard-and-fast  rules  in  treating  these  cases. 
Rest  and  protection  for  the  inflamed  tissues  is  the  one  treatment  which  is 
always  imperative,  for  without  it  good  results  cannot  be  obtained.  This  is 
the  hardest  of  all  to  be  given  outside  of  a  hospital,  for  the  laity  do  not 
understand  the  appliances,  and  more  than  half  the  time  the  child  will  have 
them  off,  or  neighbors  and  friends  will  soon  convince  the  parents  that  they 


BONE    AND   JOINT   TUBERCULOSIS   IN   MINNESOTA. GILLETTE.  253 

are  barbarous  instruments  of  torture.  We  have  known  them  to  remove 
the  apparatus  even  when  the  child  cried  for  its  reapphcation  to  relieve  its 
pain.  In  our  hospital  work  the  importance  of  the  rest  and  the  correct 
understanding  of  the  mechanical  appliance  is  the  most  difficult  part  for  the 
nurses  and  house  doctors  to  understand.  We  have  several  times  kno\\Ti  of 
the  children  in  the  hospital  asking  that  the  weight  might  be  increased  to 
relieve  their  suffering,  or  directing  the  attendants  in  its  application.  In 
short,  experience  has  taught  them,  after  long  suffering,  what  rest  will  do  for 
their  disease. 

Radical  operations  and  excisions  in  children  cannot  be  compared  with 
adult  operation  results.  The  result  of  operating  on  a  child  is  not  kno^\Ti 
when  the  wound  is  healed  and  the  disease  seemingly  eradicated,  but  when  the 
child  has  reached  his  gro"^i;h;  onl}^  then  will  we  know  how  useful  or  how 
useless  the  limb  may  be.  Whatever  method  of  treatment  is  employed,  the 
mechanical  treatment  remains  necessary,  and  vnth  any  adjuvant  it  takes 
months  and  sometimes  years  to  cure  these  tuberculous  deformities. 

This  emphasizes  the  necessity  for  a  State  hospital  for  deformed  indigent 
children. 

While  tuberculosis  is  by  far  the  most  common  cause  of  deformity  in 
children,  yet  we  have  other  diseases,  more  or  less  contagious  or  infectious, 
resulting  in  deformities.  Infantile  paralysis,  the  cerebral  palsies,  and  the 
deformities  resulting  from  anterior  poliomyelitis  next  to  tuberculosis  are  a 
great  causative  factor  in  the  production  of  crippled  children.  ]Much  can  be 
done  for  these  children,  and  they  too,  require  years  of  treatment.  These 
children  are  not  able  to  cope  with  other  children  in  the  school-room,  either 
ph3'sically  or  mentally,  hence  the  importance  of  an  educational  department 
connected  with  these  State  institutions. 

The  congenital  deformities  usually  quite  readily  respond  to  treatment, 
yet  the  mechanical  and  educational  side  must  not  be  lost  sight  of. 

The  various  other  infectious  diseases  of  bones  and  joints  and  muscles 
occurring  in  children  require  especial  attention  to  hygiene  and  diet,  which 
cannot  be  successfully  or  properly  done  when  the  purchase  of  it  would  be 
more  than  the  parents  could  afford. 

There  is  no  trouble  in  keeping  the  children  suffering  from  non-tuberculous 
deformities  from  contracting  tuberculosis  from  the  children  who  have  de- 
formities caused  by  tuberculosis.  With  numerous  rooms,  plenty  of  fresh 
air,  and  abscesses  dressed  by  properly  educated  attendants,  there  is  no  danger. 
As  all  deformed  children  in  a  general  way  require  the  same  constitutional  care 
and  education,  it  is  economic  to  have  a  State  Hospital  for  indigent  crippled 
and  deformed  children. 

The  surgery,  then,  of  infants  and  children,  and  the  medical  treatment 
as  well,  is  so  widely  different  from  adult  surgical  diseases  and  medical  diseases 


254  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

that  a  special  education  for  the  nurses  and  for  the  doctors  is  necessary,  and 
a  special  hospital,  especially  built  and  especially  equipped  for  orthopedic 
cases,  is  imperative.  This  was  the  reason  why,  in  1897,  the  Legislature 
of  the  State  of  ]\Iinnesota  authorized  the  Board  of  Regents  of  the  State 
University,  which  had  a  medical  department,  to  make  provision  for  the  care 
and  treatment  of  indigent  children  who  were  crippled  or  deformed,  or  who 
were  suffering  from  diseases  from  which  they  were  likely  to  become  crippled 
or  deformed.  The  work  was  found  so  beneficial  that  from  year  to  year  the 
appropriations  have  been  increased  as  the  work  required.  In  1906  the 
citizens  of  St.  Paul,  Minnesota,  presented  to  the  State  of  Minnesota  a  hospital 
of  about  100  beds  to  be  used  for  crippled  and  deformed  children,  and  also 
23  acres  of  land  in  the  country  to  be  used  as  a  summer  home. 

We  have  found  the  educational  department  of  immense  practical  value, 
for  many  of  these  children  have  been  obliged  to  remain  as  many  as  and 
sometimes  more  than  three  years,  and  then  left  the  hospital  not  only  cured 
of  their  deformity,  but  able  to  read  and  write,  and  in  some  instances  this 
was  the  only  education  they  ever  had  or  ever  will  receive. 

In  this  age  of  philanthropy  and  public  charities,  failure  of  the  State  and 
Government  to  make  these  unfortunates  a  public  charge  can  be  due  only 
to  lack  of  knowledge  of  their  number  and  of  the  practicability  of  their  cure. 
They  are  scattered  among  the  community,  and  no  statistics  exist  showing 
their  aggregate  number. 

It  seems  that  it  would  be  well  for  this  International  Congress  on  Tuber- 
culosis to  pass  a  resolution  urging  Congress  to  a  favorable  action  on  an 
amendment  already  introduced  and  referred  to  the  Committee  on  Census, 
the  purpose  of  which  is  to  get  official  statistics  of  crippled  and  deformed 
children.  Minnesota  was  the  first  State  in  the  Union  to  inaugurate  this 
work,  and  our  greatest  difficulty  was  the  want  of  exact  numerical  data,  for 
legislators  are  loath  to  load  the  State  with  any  unheard-of  institution.  We 
now  have  no  trouble  in  getting  adequate  funds  to  continue  the  work  in 
Minnesota,  for  our  report  plainly  demonstrates  the  economic  side  of  this 
question. 

The  State  of  Minnesota,  to  date,  has  treated  about  460  crippled  and  de- 
formed children.  We  have  had  33  deaths;  11  have  not  been  improved;  6 
have  refused  treatment.  We  have  relieved  of  disease  334  children,  and 
they  are  able  to  get  about  and  care  for  themselves.  Those  remaining  under 
treatment  give  promise  of  even  better  results.  No  matter  how  extensive  the 
disease  or  unpromising  the  result,  every  tuberculous  case  applying  to  the 
hospital  has  been  treated.  Of  these,  eighty  per  cent,  have  been  relieved  of 
all  evidences  of  active  disease. 


<9fifi      ",^!'Mfe^^' 

^\^imim^m 

1  -           ^f^ti^-'m^fh 

mSMmm 

■mm 

Most  of  these  cliildren  came  to  the  hospital  on  crutches:  others  on  cots  or  stretchers. 


A  view  of  the  twenty-three  acres  situated  at   Piialen  Park,  St.  Paul,  presented  by  the 

citizens  of  St.  Paul. 


The  scliool-rooin. 


BONE   AND   JOINT  TUBERCULOSIS   IN   MINNESOTA. — GILLETTE.  255 

Como  el  Estado  de  Minnesota  Cuida  por  los  Ninos  Indigentes  Afectados 
de  Tuberculosis  de  los  Huesos  y  de  las  Articulaciones. — (Gillette.) 

En  1897  el  Estado  de  ]\linnesota  fue  el  primer  Estado  apropiar  dinero 
para  el  cuido  de  los  nirios  indigentes.  Dede  1897  cierto  numero  de  los  otros 
estados  han  hecho  apropiaciones  semejantes.  Al  presente  no  es  una  cosa 
dificil  conseguir  dinero  de  cada  Estado  para  el  tratamiento  y  educaeion  de 
esta  clase  de  ninos.  Esto  es  de  una  importancia  especial  por  que  como 
Unas  tres  cuartas  partes  de  estos  ninos  indigentes  estan  afectados  de  tuber- 
culosis de  los  huesos  y  de  las  articulaciones.  Muchos  de  ellos  tienen  com- 
plicaciones  de  tuberculosis  de  los  pulmones,  intestinos,  etc.,  y  un  por  ciento 
considerable  de  ellos  sufren  de  abscesos  y  otras  afecciones,  no  solamente  de 
origen  tuberculoso,  sino  que  tambien  contienen  otros  microorganismos 
infecciosos.  Muchos  de  estos  ninos  concurren  a  las  escuelas  publicas,  y  no 
existe  pro\'isi6n  en  cuanto  a  la  proteccion  de  los  ninos  sanos  en  las  escuelas, 
6  para  prevenir  el  contagio  en  sus  propias  familias. 

Algunes  veces  se  necesitan  muchos  anos  para  curar  a  un  niiio  afectado 
de  tuberculosis  de  los  huesos  y  de  las  articulaciones,  y  por  lo  tanto  el  aspecto 
de  la  educaeion  es  un  problema  importante.  Los  ninos  deberan  ser 
educados,  y  tambien  debera  darseles  una  instruccion  especial  en  ciertas 
clases  de  trabajo  a  fin  de  que  mas  tarde  estos  puedan  soportarse  con  sus 
propios  esfuerzos. 


Comment  I'etat  de  Minnesota  prend  soin  des  enfants  pauvres  attaints 
de  tuberculosa  osseuse  at  articulaira. — (Gillette.) 

En  1897  la  Legislature  de  I'Etat  de  Minnesota  a  la  premiere  votaient  une 
subvention  pour  le  soin,  par  TEtat,  des  enfants  estropies  et  difformes. 
Depuis  1897,  nombre  d'Etats  ont  imite  cet  exemple.  A  I'heure  presente, 
il  ne  serait  pas  difficile  d'obtenir  de  I'argent  de  n'importe  quel  Etat  de  TUnion 
pour  traitor  et  elever  cette  classe  de  malheureux. 

Cela  est  d'une  grande  importance,  car  I'expcrience  a  montre  qu'en\'iron 
les  trois  quarts  de  ces  enfants  estropies  ou  difformes  sont  atteints  de  la 
tuberculose  des  os  et  des  articulations.  Chez  un  grand  nombre  il  y  a  com- 
plication de  tuberculose  pulmonaire,  intestinale,  etc.;  beaucoup  ont  des 
abc^  et  des  ulceres  purulents  qui  contiennent  non  seulement  des  bacilles 
de  tuberculose,  mais  encore  d'autrcs  raicro-organismes  infecticux.  Beaucoup 
de  ces  enfants  vont  k  I'^cole  publique  et  Ton  n'a  pris  aucune  mesure  pour 
protdger  leurs  camarades  sains  ou  pour  empecher  la  contagion  dans  leurs 
propres  families. 

II  faut  parfois  un  nombre  d'annees  pour  guerir  un  enfant  atteint  de 
tuberculose  osseuse  et  articulaire  et  le  probleme  de  leur  Education  est  de 


256  SIXTH   INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

la  plus  haute  importance.  Cette  education  leur  est  due,  aussi  bien  qu'une 
instruction  professionnelle  sp^ciale  qui  puisse  leur  servir  plus  tard  et  leur 
permettre  de  gagner  leur  vie. 


DISCUSSION. 

Dr.  Henry  W.  Frauenthal  (New  York)  reported  a  number  of  cases  in 
which  he  had  used  the  bismuth  paste  successfully.  He  also  spoke  favorably 
of  the  Bier  hyperemic  treatment. 

Dr.  B.  H.  Whitbek  (New  York)  said  that,  something  over  a  year  ago, 
a  hospital  had  been  established  at  Sea  Breeze,  Long  Island,  and  that  marked 
success  had  been  obtained  in  the  treatment  of  surgical  tuberculosis  at  that 
hospital.  The  patients  seemed  to  do  so  much  better  than  they  did  in  the 
hospitals  in  the  city.  The  little  patients  were  allowed,  in  the  majority  of 
cases,  to  take  their  daily  sea-bath,  after  which  a  new  dressing  was  applied. 

Dr.  Eugene  Caravia  (New  York)  said  that  these  lesions  were  only  local 
manifestations  of  a  general  tuberculosis,  and  while  these  local  remedies,  the 
bismuth  paste,  hyperemia,  etc.,  were  good  for  the  local  condition,  yet  they 
did  not  act  upon  the  general  condition.  He  believed  something  should  be 
used  which  would  act  upon  the  general  condition,  and  felt  that  we  had  such 
a  remedy  in  Cuguillere's  vegetable  serum. 

Dr.  Bradford,  in  closing,  agreed  with  Dr.  Caravia  that  the  treatment 
of  the  general  condition  was  most  important,  but  he  believed  fresh  air  was 
the  most  important  measure  in  this  direction. 

Dr.  Beck,  in  closing,  said  it  was  true  that  we  had  to  treat  the  general 
condition,  but  that  did  not  prevent  us  from  treating  the  sinuses.  In  the  ab- 
sence of  any  absolute  remedy  for  the  general  treatment  of  tuberculosis,  we 
should  treat  the  local  condition  as  best  we  could. 

Dr.  Meyer,  in  closing,  said  we  should  individualize  in  treating  tuberculosis 
— that  is,  not  attempt  to  have  any  fixed  way  of  treating  every  form  of  surgical 
tuberculosis,  but  treat  each  condition  according  to  the  indications  in  that 
case.  In  certain  cases  where  the  lungs  were  also  involved,  the  lung  suction 
mask  should  be  used  also. 


OPEN-AIR    TREATMENT    OF    SURGICAL 
TUBERCULOSIS. 

By  De  Forest  Willard,  M.D., 

Philadelphia. 


The  facts  presented  in  this  paper  for  discussion  are  intended  to  encourage, 
not  the  trained  sanatorium  expert,  but  the  family  physician,  in  his  fight 
against  early  tuberculosis  of  the  bones  and  joints.  Such  a  physician  may 
have  carefully  tested  the  effect  of  tliis  method  in  tuberculosis  of  the  lungs, 
yet  it  may  never  have  occurred  to  him  that  a  tuberculous  joint  requires  the 
same  form  of  treatment. 

It  is  upon  the  family  physician  that  we  must  depend  for  the  early  recog- 
nition of  these  tuberculous  conditions,  in  order  that  he  may  at  once  combat 
them  or  refer  the  case  to  a  trained  specialist.  The  first  few  weeks  of  a  tuber- 
culi^us  infection  offer  the  golden  opportunity  for  arrest  and  abortion  of  the 
invasion,  and  of  cure  with  good  function  mobility.  It  should  always  be 
remembered  that  the  onset  of  joint  tuberculosis  is  insidious,  and  usually 
without  violent  symptoms.  Early  diagnosis  in  hip  or  knee  or  spine  disease, 
as  indicated  by  brain  recognition  of  occult  pain,  as  demonstrated  by  muscular 
rigidit}'' — the  guarding  of  the  joint — is,  therefore,  of  prime  importance. 
To  diagnose  a  slight  intermittent  limp,  accompanied  by  fixation  of  the  joint, 
as  a  case  of  rheumatism  is  absolutely  unjustifiable,  since  rheumatism  of  a 
single  joint  in  a  child  without  positive  symptoms  practically  never  exists. 

Not  until  physicians  learn  that  an  enormous  percentage  of  lifelong 
deformities  of  hip,  knee,  spine,  etc.,  prolonged  suppurations,  and  loss  of  life 
are  due  to  their  careless  and  ignorant  diagnosis  of  "rheumatism"  will  these 
dreadful  results  cease.  Ninety-five  per  cent,  of  joint  tuberculous  cases  are 
criminally  treated  for  rheumatism  for  weeks  or  months,  when  a  five  minutes' 
examination  of  the  naked  child  would  have  convinced  the  medical  attendant 
that  a  serious  disease  was  threatened. 

For  thirty  years,  even  before  Koch's  discovery  of  the  tubercle  bacillus, 
1  have  persistently  advocated  and  practised  the  fresh-air  method  of  treatment 
for  tuberculosis  of  hip  and  spine,  and  have  never  known  it  to  be  without 
benefit.* 

At  the  outset  let  it  be  definitely  understood  that  the  employment  of 

♦Willard:  Trans.  Amer.  Med.  Assoc,  1880.     Jour.  Amer.  Med.  Assoc,  July,  1903. 
VOL.  II— 9  257 


258  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

the  open-air  treatment  for  surgical  tuberculosis  in  no  sense  implies  that 
either  surgical  or  mechanical  measures  are  to  be  neglected  in  the  slightest 
degree.  Aspiration,  injection,  incision,  erasion  of  the  diseased  focus,  excision, 
amputation,  any  of  these  measures  may  be  necessary  in  individual  and  ad- 
vanced cases,  but  both  before  and  after  operation  the  surroundings  of  the 
patient  will  have  much  to  do  with  cure.  Mechanical  protection,  immobil- 
ization, traction,  fixation,  and  rest  are  also  essential  requisites.  As  an  im- 
portant accessory  to  these  surgical  and  mechanical  measures,  however, 
pure  fresh  air  taken  into  the  lungs  in  25,000  daily  doses  should  certainly 
commend  itself  to  intelligent  physicians  in  preference  to  tliree  doses  per  day 
of  nauseous  drugs,  which  may  interfere  with  digestion  rather  than  improve 
it.  This  adjunct  should  no  more  be  neglected  than  should  an  abundance  of 
food,  sleep,  and  rest  for  oxygenating,  vivifying,  and  renewing  tissues,  im- 
proving digestion  and  circulation.* 

Tuberculin  and  serum  injections;  vaccine  therapy,  regulated  by  the 
opsonic  index;  immunization;  Bier's  hj^eremic  congestion;  bismuth  in- 
jections, all  have  a  limited  but  less  important  place. 

The  results  of  open-air  treatment  are  more  positive  in  tuberculosis  of  the 
bones  and  joints  even  than  in  lung  diseases. f 

]\Iany  cases  formerly  requiring  the  knife  are  now  successfully  combated 
and  often  cured  without  open  suppuration,  and  oftentimes  with  decided  im- 
provement in  function.  I  recall  a  patient  whose  hip  had  been  excised,  and 
on  whom  three  or  four  subsequent  erasions  had  been  performed  for  per- 
sistent suppuration,  with  amyloid  liver  and  spleen  and  kidneys,  and  a 
dozen  discharging  sinuses,  and  in  whom  further  operative  interference  was 
deemed  inadvisable,  yet  who  recovered  wth  closed  sinuses  after  a  short 
residence  at  the  seashore,  and  when  seen,  ten  years  later,  was  in  excellent 
health. 

Tubercle  bacilli  die  if  exposed  for  a  short  time  to  the  rays  of  the  sun. 
Laboratory  experiments  show  that  bacterial  proteids  are  broken  up  by  direct 
sunlight,  so  that  the  nitrogenous  elements  after  exposure  exist  in  soluble 
form. J  Tubercle  bacilli  thrive  in  darkness,  confined  air,  and  filth;  they  die 
in  sunshine,  and  are  inhibited  by  cold  fresh  air  and  by  increased  general  health. 
To  expose  the  patient  and  even  the  affected  joint  to  the  direct  rays  of  the  sun 
is  therefore  beneficial.  The  benefit  of  sunshine  upon  plants,  animals,  and 
men  is  too  well  known  to  be  ignored.  Every  plant  and  tree  turns  to  the 
light.  Even  the  arrest  of  the  ultra-violet  rays  of  sunshine  by  glass  in  the 
windows  may  have  an  influence. 

Colorado,  California,  Arizona,  and  New  Mexico  undoubtedly  owe  their 

♦Wilson:    Penna.  Med.  Jour.,  Jan.,  1906.     Halsted:    Amer.  Med.,  Dec,  1905. 

t  Bradford:  Boston  Med.  and  Surg.  Jour.,  Jan.,  1906. 

j  Vaughn:  Jour.  Amer.  Med.  Assoc,  1908,  section,  Diseases  of  Children. 


OPEN-AIR   TREATMENT    OF    SURGICAL   TUBERCULOSIS.^WILLARD.        259 

reputation  largely  to  the  extra  hours  of  sunshine  and  the  time  permissible  for 
outdoor  life.  Tuberculosis  increases  when  cUmatological  conditions  compel 
individuals  to  be  confined  in  dark,  close  rooms.  Cold  inhibits  bacterial 
development,  but  does  not  kill.  It  is  beneficial  in  proportion  as  it  stimu- 
lates muscular  activity,  appetite,  sleep,  circulation,  and  increases  oxygen- 
ation and  vital  cell-resistance  and  nutrition.  Its  benefit  is  largely  depend- 
ent upon  the  purity  of  the  air  and  the  hours  per  day  that  can  be  spent  out 
of  doors  in  its  influence.  Even  a  temperature  at  zero  is  not  injurious  if 
proper  clothing  is  provided.  Other  surgical  conditions  requiring  fresh-air 
treatment  are  tuberculosis  of  the  glands,  kidneys,  testes,  prostate,  peri- 
toneum, etc. 

The  combination  of  sunshine,  fresh  air,  rest,  and  fixation  of  a  diseased  joint 
during  the  active  and  painful  stage  when  confined  to  bed  is  important  to  pre- 
vent the  addition  of  mixed  inflammatory  infection  to  the  tubercular  process. 
In  young  children  this  treatment  is  best  accomplished  by  placing  the  little 
patient  upon  a  canvas-covered  stretcher  frame  of  bamboo,  w^ood,  or  gas-pipe, 
from  which  it  need  not  be  removed  day  or  night.  Even  a  nursing  baby  can 
thus  be  gently  cared  for  with  the  least  possible  movement  of  the  diseased 
area.  An  older  child  can  also  be  thus  carried  about  the  house  by  one  or  two 
persons,  lifted  upon  a  go-cart  or  wheeled  litter  or  express-wagon,  or  placed  on 
trestles  or  stools  on  a  veranda  or  under  a  tree  without  changing  the  horizon- 
tal position  or  removing  the  pulley  extension,  or  interfering  in  any  way 
with  an  open-air  life.  When  the  painful  stage  has  passed,  ambulatory 
treatment  on  crutches  can  be  commenced,  the  involved  joint  being  fixed 
and  protected  by  gj^sum,  leather,  or  binder's  board  splint  or  steel  appara- 
tus, with  high  cork  shoe  on  the  well  foot. 

For  the  wealthy,  the  problem  is  not  difficult.  The  mountains,  the  sea- 
shore, the  Adirondacks,  the  dry  sunny  slopes  of  the  Rockies,  the  hills  and 
plains  of  Europe  and  other  countries,  with  comfortable  sanatoriums  and  the 
advantages  of  change  of  location,  are  readily  obtainable,  and  under  judicious 
advice  and  treatment  by  a  wise  orthopedic  surgeon  hundreds  of  joints  can 
be  saved  from  life-long  deformity.  California  has  a  large  reputation  in  the 
treatment  of  tuberculosis,  but  it  is,  of  course,  necessary,  as  in  Colorado, 
Arizona,  and  other  sections,  that  judgment  should  be  used  in  the  selection  of 
a  proper  region.  California  is  such  an  enormous  State  that  extreme  diversi- 
ties of  heat  and  cold,  dryness  and  dampness,  are  to  be  found.  In  the  north- 
ern citrus  belt,  high  upon  the  Sierras,  100  miles  from  San  Francisco,  many 
tuberculous  patients  find  not  only  healthful  surroundings,  but  are  able  also 
to  maintain  a  profitable  existence. 

As  90  per  cent,  of  the  cases,  however,  are  poor,  the  financial  question 
presents  a  most  serious  problem  to  be  solved  in  the  treatment  of  this  class. 
Children  with  bone  or  joint  diseases  in  the  large  cities,  with  parents  barely 


260  SIXTH   INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

able  to  earn  enough  to  supply  food  and  clotliing,  probably  consumptive  and 
living  in  closely  crowded  quarters,  must  be  removed  to  healthful  surroundings 
if  lives  are  to  be  saved.  Also  the  large  number  of  adolescents  and  adults 
with  tuberculous  bone  diseases  must  be  provided  for.  When  they  are  de- 
pendent upon  their  own  exertions  for  a  living,  or  have  others  dependent  upon 
them,  to  advise  them  to  go  to  Arizona  or  Colorado  is  to  recommend  the 
impossible. 

Orthopedic  Hospitals. — For  this  class,  orthopedic  hospitals  of  large 
accommodations,  thoroughly  equipped  with  appliances,  and  attended  by 
surgeons  specially  conversant  with  the  needs  of  these  cripples,  are  all  im- 
portant. In  adcUtion,  each  State  should  provide  surgical  sanatoriums  of 
large  size,  in  carefully  selected  regions,  at  both  mountain  and  seashore,  and 
separated  from  lung  cases. 

Hospitals  for  children  with  tuberculous  bones  and  joints  should  be  sepa- 
rate from  general  surgical  wards,  as  the  great  danger  in  suppurative  cases  is 
from  the  mixed  infection,  which  destroys  so  many  lives.  The  presence  of 
this  class  of  cases  among  fresh  osteotomies,  tenotomies,  and  other  clean 
wounds,  is  also  dangerous.  Dressings  saturated  with  tuberculous  pus 
should  be  at  once  burned  or  disinfected.  Adolescents  and  adults  of  this 
class  should  also  be  separated  from  general  surgical  wards.  Another  im- 
portant reason  for  orthopedic  hospitals  thoroughly  equipped  and  attended  by 
surgeons  especially  trained  for  this  work  is  the  fact  that  these  patients, 
being  usually  chronic  cases,  are  apt  to  be  neglected  in  the  rush  of  active 
general  surgical  work. 

Sun  Porches,  Solaria,  Roof-gardens. — In  the  cities,  hospital  wards 
should  be  built  to  open  south,  east,  and  west,  to  admit  both  sun  and  air. 
At  the  south  end  should  be  built  the  most  important  part  of  the  ward,  i.  e., 
a  porch  sufficiently  large  to  accommodate  all  cases  confined  to  bed.  If  no 
thresholds  are  made,  and  if  beds  are  provided  with  five-inch  wheels,  these 
beds  can  be  rolled  into  the  ward  as  necessary  for  surgical  dressings,  etc.  The 
porch  should  be  one-half  covered,  glass-inclosed  in  winter  and  provided 
with  moderate  heat,  so  that  an  abundance  of  cold  air  can  be  admitted.* 

For  patients  lying  in  bed  upon  a  porch  the  wooden  wainscoting  should 
reach  in  height  to  the  bottom  of  the  mattress,  to  keep  out  cold  and  wind.  For 
twelve  inches  above  this  the  sides  should  be  of  glass,  to  permit  the  child  to 
look  out  upon  the  grass  and  trees,  even  when  lying  flat.  Above  this,  every 
alternate  glass  sash  should  be  hinged  so  as  to  open  inward,  and  be  fastened 
flat  against  its  neighbor  with  hook,  or  else  hinged  above.  If  the  frames  are 
removed  in  summer,  awnings  should  be  erected  to  protect  from  wind  and  ex- 
cessive sun  and  from  rain  during  thunder-showers.  This  method  will  per- 
mit the  use  of  netting  to  protect  against  mosquitos  and  flies,  especially  in 
*  Willard:  Trans.  Amer.  Orth.  Assoc,  1898,  Orth.  Dept.  University  Hospital 


OPEN-AIR   TREATMENT   OF    SURGICAL   TUBERCULOSIS. — WILLARD.        261 

malarial  regions.  One  portion  should  be  without  roof,  where  diseased  joints 
may  be  fully  exposed  to  the  direct  sun-rays.  Eyes  can  be  protected  by  colored 
glasses  or  by  a  small  doll's  carriage  green  umbrella,  attached  to  the  head  of 
the  bed.  Upon  such  a  porch  the  children  should  sleep  winter  and  summer, 
night  and  day,  abundant  clothing  being  provided.  Separate  screens  or 
canvas  curtains  should  be  provided.  The  night  nurse  in  charge  can  remain 
in  a  warmer  room  and  watch  the  children  through  a  glass  partition,  and 
when  necessary,  the  bed  can  be  rolled  into  the  ward. 

When  such  a  porch  is  impossible  in  a  city  hospital,  a  roof-garden,  one 
half  covered,  the  other  exposed,  reached  by  elevator,  is  an  excellent  sub- 
stitute, and  will  answer  both  for  a  sleeping  porch  and  a  day  playroom. 
Private  houses  can  be  readily  built  with  such  an  outing  space.  A  balustrade 
to  prevent  accidents  and  glass  inclosure  in  winter  permit  use  during  the 
entire  year.  If  the  hospital  grounds  are  large,  tents  or  shacks  may  be 
erected. 

Sleeping  out  of  doors,  like  all  other  matters,  must  be  wisely  and  judi- 
ciously planned  and  provided  for.  At  first  every  precaution  must  be  taken 
to  guard  the  patient  from  too  sudden  exposure  and  change.  In  the  case 
of  patients  confined  to  bed,  as  in  severe  suppurative  lesions  of  the  spine  or 
other  joints,  it  is  important  that  means  for  surgical  dressings,  cleansing,  bath- 
ing, etc.,  shall  be  provided  in  a  warmer  atmosphere.  It  is  for  this  reason  that 
tent  life  is  not  as  convenient  as  a  porch  or  shack  connected  with  a  warm 
room  into  which  the  bed  with  large  five-inch  wheels  can  be  easily  rolled. 
If  this  is  not  possible,  a  small  patient  can  be  readily  moved  if  laid  permanently 
upon  a  canvas-covered  gas-pipe  frame,  and  placed  upon  a  wheeled  litter, 
go-cart,  express-wagon,  or  cart.  Cases  able  to  move  about  on  crutches  or 
apparatus  can  be  readily  managed. 

To  be  entirely  in  the  open  air  is  to  avoid  drafts  and  colds,  but  so  long  as 
thunder-storms,  snow,  rain,  etc.,  must  be  provided  for,  the  porch  offers  the 
best  solution  of  the  difficulties,  especially  for  helpless  patients. 

A  canvas  tent  theoretically  is  excellent,  but  practically  it  is  very  hot 
in  summer  days,  even  when  covered  with  a  fly,  and  unless  floored  and  sides 
raised,  it  is  damp  in  wet  weather  and  does  not  give  free  circulation  of  air.  In 
winter,  if  closed  and  provided  with  a  stove,  it  is  stuffy  and  ill  ventilated. 
The  disposal  of  feces  and  the  arrangements  for  bathing,  surgical  dressings, 
etc.,  are  also  more  difficult  in  a  canvas  tent  for  bed  cases.  The  wooden 
barracks  or  shacks  used  at  tuberculosis  sanatoriums  are  much  better.  The 
best  method  in  summer  for  convalescent  cases  who  are  old  enough  and 
well  enough  to  become  ambulatory  would  be  to  sleep  in  the  open,  with  a  tent 
in  close  proximity  for  escape  during  rain.  A  bed  out  of  doors  can  be  made 
much  warmer  by  placing  beneath  the  mattress  several  layers  of  wrapping 
or  builder's  paper,  or  even  newspapers. 


262  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

Convalescent  Hospitals. — The  site  of  convalescent  hospitals  must  be 
selected  with  a  view  to  healthful  surroundings  and  for  accessibility  by 
skilled  orthopedic  surgeons. 

An  excellent  t3^e  of  this  class  is  seen  at  Wellesley  Hills,  near  Boston,  as 
planned  by  Burrell*  and  others.  These  wooden  shacks  or  barracks  are  in- 
exjDensively  built,  with  glass  sides  and  sunny  plajTOoms,  and  open  freely 
at  the  sides  and  roof.f  The  temperature  at  night  sometimes  falls  to  zero, 
but  as  the  protection  of  the  children  is  abundant,  they  are  steadily  improved 
in  color,  appetite,  weight  and  strength,  while  hemoglobin  is  increased.  J  The 
clothing  at  night  in  the  shack,  if  needed,  is:  sliirt;  Canton-flannel  night- 
govvTi;  red  flannel  jacket;  long  Shaker-flannel  gown  with  hood;  socks  (or  long 
boots  made  of  eiderdowTi),  reaching  above  the  knees;  six  or  eight  blankets. 
There  is  no  difficulty  in  keeping  a  patient  comfortable  with  a  temperature 
of  10°  to  20°  F.  if  abundant  clothing  and  a  nightcap  are  used.  All  that  is 
necessary  is  that  the  nose  be  uncovered  to  receive  the  pure  cold  air.  A 
down  quilt  is  light  and  warm,  and  if  perforated,  does  not  induce  perspiration. 

Urination  in  boys  is  readily  managed  beneath  the  covers,  and  also  in 
girls,  if  a  small  pus-basin  is  used.  A  skilful  nurse  can  also  change  diapers 
quickly  without  exposure. 

Extreme  cold,  however,  is  not  important.  It  is  fresh  pure  air  that  is 
needed,  and  this  can  be  obtained  by  admitting  it  in  abundance  and  yet 
tempering  it  by  heat. 

B.-uiRACKS,  OR  Shacks,  or  Bungalows,  or  Cabins,  or  Lodges. — 
For  two  persons  well  enough  to  assist  themselves,  the  simplest  and  most 
effective  form  of  shack  is  a  small  light  wooden  structure  raised  on  supports, 
and  with  all  four  glass  sides  hinged  at  the  upper  border,  to  be  raised  out- 
wardly so  as  to  act  as  sunshades  by  day  and  to  be  open  at  all  times  except 
in  rain  or  snow.  Inside  nettings  will  protect  from  mosquitos.  An  open  porch 
can  be  added.  Newspapers  or  rubber  cloth  beneath  the  mattress  AAdll  add 
greatly  to  the  warmth  of  the  bed.  A  nearby  earth-closet  is,  of  course, 
convenient.  An  adjoining  tent  furnishes  a  good  bath-room  for  the  summer. 
For  extremely  windy  nights  in  winter,  inside  denim  or  Japanese  curtains  can 
be  arranged. 

Industrial  Schools. — In  the  Widener  Industrial  School  for  Crippled 
Children  in  Philadelphia  the  children  spend  a  large  portion  of  the  time  day 
and  night  in  the  open  air;  good  food  is  given,  and  teaching  is  conducted 
as  much  as  possible  out  of  doors.  Outdoor  sports  and  occupations  are  en- 
couraged as  much  as  possible.     The  improvement  in  flesh,  color,  and  health 

*  Burrell:  Trans.  Mass.  Med.  Soc,  June,  1903. 

t  Thorndyke:  Orthopedic  Surgery,  219.  Adams:  Boston  Med.  and  Surg.  Jour., 
1906,  cliv,  71. 

X  Bradford:  Tuberculosis  in  Massachusetts,  1908;  Report  Mass.  State  Com.,  1908, 
pp.  99-114. 


OPEN-AIR   TREATMENT   OF   SURGICAL   TUBERCULOSIS. — WILLARD.        263 

is  remarkable.  Although  the  school  is  on  the  outskirts  of  a  large  city, 
30  acres  of  ground  are  occupied.  For  a  winter  playground  a  large  area  is 
asphalted  in  order  that  it  may  be  quickly  cleaned  of  snow  and  dried.  For 
shelter,  a  pavilion  with  glass  roof  and  sides  gives  full  access  to  the  sun,  and 
toilet-rooms  for  girls  and  boys  are  provided.  The  school  provides  hospital 
treatment  with  educational  and  manual  training  until  the  cripple  arrives 
at  the  age  of  twenty-one,  or  has  secured  a  self-sustaining  occupation. 

Forest  Schools. — For  feeble  children,  forest  schools  should  be  in- 
augurated where  instruction  can  be  given  to  the  children  with  their  lungs 
filled  with  pure  air  and  their  brains  supplied  with  well-oxygenated  blood. 
Undoubtedly,  learning  under  such  surroundings  would  be  both  rapid  and 
attractive.  Studies  in  natural  liistory,  of  birds,  animals,  trees,  plants,  rocks, 
etc.,  would  be  simple  and  easy,  and  dangers  of  contagion  would  be  lessened 
and  a  more  vigorous  youth-life  secured  for  both  sexes.  The  pallid  city  child 
under  such  conditions  would  soon  evidence  renewed  color  and  vigor  of 
resistance.  To  the  teachers,  also,  such  a  system  would  add  greatly  to  their 
physical  being  and  their  brain  alertness  and  interest.  Protection  from  rain 
would  be  the  only  question  to  be  solved  during  the  summer  months.  Seats 
and  desks  could  be  covered  with  a  tent.  The  German  Waldschule  are  a  good 
type. 

Sanatoriums. — Sanatoriums  for  surgical  tuberculosis  should  be  entirely 
separated  from  institutions  designed  for  phthisical  cases.  They  should 
be  provided  by  each  State  at  both  seashore  and  mountain;  should  have 
large  accommodation,  but  with  many  small  wooden  buildings.  The  surround- 
ings should  be  healthful,  and'  if  possible  in  a  pine  forest  region. 

Pennsylvania  last  year  appropriated  $1,000,000  for  the  establishment  of 
tuberculosis  sanatoriums  and  dispensaries.  One-story  cottages,  27  by  24 
feet,  to  accommodate  eight  patients,  well  ventilated  and  arranged  with  pro- 
tection from  storm,  were  erected.  The  cottages  will  face  southeast  to  se- 
cure the  greatest  possible  amount  of  sunshine  on  all  four  sides.  Surgical 
tuberculous  cases  will,  of  course,  be  separated  from  lung  patients.  Exer- 
cise, amusements,  and  work  will  be  appropriately  regulated  to  the  capacity 
of  the  individual. 

Sanatoriums  have  now  been  largely  established,  however,  for  medical 
cases  in  Pennsylvania,  New  York,  Vermont,  IMassachusetts,  New  Jersey, 
Iowa,  Missouri,  j\Iaryland,  and  in  other  States;  but  separate  institutions  for 
the  surgically  tuberculous  are  only  now  being  located. 

Sanatoriums  are  of  especial  value  in  the  early  stages  of  joint  or  bone 
tuberculosis  in  proportion  as  they  educate  patients  to  lead  a  regulated  and 
healthful  method  of  life  in  the  sunshine  and  open  air,  day  and  night;  to 
take  a  proper  amount  of  health-giving  food;  to  sleep  much  and  to  give 
absolute  rest  to  the  diseased  area.     God's  sunshine  and  God's  pure  air, 


264  SIXTH    INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

wherever  obtained,  with  regional  tissue  rest,  are  more  potent  than  all  other 
forces  combined. 

Sanatoriums  for  joint  cases  require  smooth  grounds,  as  many  patients  are 
upon  crutches  or  splints  and  cannot  move  about  except  upon  level  firm 
surfaces,  thus  preventing  life  in  the  woods,  where  the  ground  is  soft  and  rough. 

When  surgeons  and  patients  realize  that  25,000  doses  of  pure  air  per  day 
are  infinitely  better  than  three  doses  of  nauseous  drugs  that  impair  appetite 
and  digestion,  then  will  the  control  of  surgical  tuberculosis  be  well  advanced. 

Probably  the  most  improvement  would  be  gained  in  the  mountains  for 
six  months  in  summer,  the  winter  months  being  passed  at  or  near  the  sea- 
shore in  warm  regions,  where  ample  porches  and  smooth  boardwalks  would 
permit  a  constant  open-air  life. 

As  cleanly  surgical  attendance  is  necessary,  each  sanatorium  should  be 
provided  with  an  aseptic  operating  room  and  an  equally  clean  room  for 
surgical  dressings. 

Sleeping  Tents  and  Canopies. — Sleeping  tents  and  canopies  are  useful 
for  patients  who  cannot  secure  an  outdoor  porch. 

Another  method  is  by  the  window  tents  that  are  now  largely  manufac- 
tured. These  tents  are  so  arranged  at  the  window  that  the  patient's  head 
is  outside  the  door,  while  the  body  is  within,*  or  a  cot  can  be  so  constructed 
on  wheels  that  the  head  of  the  patient  can  be  pushed  outside  the  window 
line  at  night,  and  withdrawn  in  case  of  rain  or  snow,  or  an  awning  (without 
fringe)  may  be  placed  over  the  window.  The  window  can  be  brought  down 
close  to  the  body  of  the  patient  and  air  excluded  from  the  thorax  by  a  loose- 
ly tucked  blanket  or  by  flannel.     A  woolen  nightcap  is  desirable. 

"Sending  the  patient  to  the  country"  will  accomplish  but  little  unless 
locality,  environments,  and  food  facilities  are  carefully  considered  by  the 
surgeon.  Many  country  houses  are  notoriously  unhygienic  in  their  surround- 
ings. Abundance  of  sunshine,  good  food,  pure  air  free  from  dust  and  smoke, 
and  a  life  of  moderate  and  systematic  exercise  that  will  tire,  but  not  ex- 
haust, are  good  rules. 

Home  Treatment. — When  it  is  impossible  to  remove  the  patient  from 
home,  conditions  can  be  greatly  benefited  by  a  wise  and  judicious  system  of 
supervision.  The  cooperation  of  surgeon,  nurse,  and  visitor  is  important 
in  the  instruction  of  patients  as  to  detail  of  daily  life.  Frequently  it  is  im- 
possible, among  the  poor,  to  secure  outdoor  sleeping.  Under  these  conditions 
the  best  obtainable  quarters  will  be  a  room  with  as  many  windows  as  possible 
for  the  night,  and  a  southern  exposure,  if  feasible,  by  day.  Unfortunately, 
it  is  often  impossible  for  the  family  to  supply  sufficient  heat  or  bed-clothing 
in  winter,  with  the  result  that  all  huddle  together  in  close  quarters.     Careful 

♦Harris  Window  Tent;  Walsh  Window  Tent,  Morris,  111.;  Do-wah-jack  Portable 
Co.,  Chicago. 


OPEN-AIR   TREATMENT   OF    SURGICAL   TUBERCULOSIS. — WILLARD.        265 

instructions  as  to  habits,  food,  air,  etc.,  will  change  doubtful  cases  into  hope- 
ful ones.  The  diet  must  be  nutritious  and  easily  assimilated, — milk,  eggs, 
meat,  bread;  as  much  butter  as  can  be  afforded  (in  place  of  cod-liver  oil)» 
fruits,  fats,  proper  hours  of  rest,  etc. 

Fresh  air  at  night  can  be  secured  by  placing  the  head  of  the  bed  at  an 
open  window,  the  head  being  protected  by  a  handkerchief  or  nightcap. 
The  body  can  be  shut  off  from  the  head  by  curtains  tacked  to  the  sides  and 
top  of  the  window,  or  supported  on  wire  or  wooden  frames,  and  tucked  about 
the  neck  and  chest.* 

For  a  patient  in  a  family  of  even  moderate  circumstances  in  the  country 
or  in  a  village,  with  space  between  the  houses,  or  even  on  the  roofs  or  the 
yard  of  city  houses,  much  can  be  accomplished  toward  providing  an  outdoor 
life.  Any  sunny  room  or  yard  or  open  porch  covered  with  roof  or  awning 
offers  excellent  facilities.  A  cheap  balcony,  with  awning,  a  flat  roof  or  a 
flat  platform  over  a  sloping  roof,  can  be  constructed  at  slight  cost.f 

The  principal  diSiculty  is  to  provide  against  thunder-storms  and  wind  in 
summer  and  rain  and  snow  in  winter.  On  account  of  this  a  porch  is  better 
than  a  tent,  as  screens  and  awnings  are  more  easily  adjusted.  A  child,  if 
confined  to  the  recumbent  position,  should  be  continuously  on  a  bed-tray 
or  frame  for  convenient  moving.  A  tent  in  a  yard  is  useful,  but  if  closed,  is 
no  better  than  a  room.  For  movable  cases  a  nearby  shade  tree  is  refreshing 
in  summer.  An  army  tent,  7x7  feet,  with  fly,  can  be  procured  for  seven 
or  eight  dollars.  An  open  shack  is  useful,  but  is  not  so  easily  moved 
for  summer  and  for  winter  use  as  is  the  tent. 

Day  Camps. — Even  day  camps  situated  within  easy  access  from  the  larger 
cities  are  serviceable  according  to  the  degree  to  which  they  can  be  utilized. 
Even  a  few  hours  of  breathing  pure,  healthful,  life-giving  air  is  infinitely 
better  than  living  continuously  in  crowded  alleys  and  rooms. 

Walking  cases  of  joint  tuberculosis  can  be  benefited  just  in  proportion 
to  the  hours  that  they  can  be  brought  into  contact  with  hygienic  sur- 
roundings; i.  e.,  provided  the  joints  are  protected  against  traumatisms 
en  route.  Sanatoriums,  if  properly  located  and  scientifically  conducted, 
should  yield  10  per  cent,  better  results  than  day  camps,  and  the  latter  10  to 
20  per  cent,  better  results  than  home  treatment,  especially  in  tenements.  J 

Food. — One  of  the  important  elements  of  the  outdoor  life  is  its  stimulat- 
ing effect  upon  appetite,  nutrition,  and  assimilation.  Any  medicine  that 
interferes  with  digestion  should  be  omitted  or  regulated.  Creosote,  if 
administered,  should  be  given  in  pepsin  or  in  peptonoids.  A  few  drops  of 
ether  will  correct  the  regurgitations  after  cod-liver  oil.     Pepsin  is  valuable 

*  Jour.  Amer.  Med.  Assoc,  Dec,  1907. 

t  Jour.  Amer.  Med.  Assoc,  1907,  xlix,  9,  755;  Boston  Med.  and  Surg.  Jour.,  Feb., 
1906. 

X  The  early  labors  of  Bennett,  Hutt,  and  others  are  yielding  excellent  fruit. 


266  SIXTH    INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

in  assisting  comfortable  retention  of  food;  so  are  the  mineral  acids  and  mix 
vomica — the  latter  much  better  than  strychnin.  Milk,  buttermilk,  whey, 
junket,  custards,  koumis,  eggs,  raw  or  heated  in  a  glass  of  boiling  water, 
meats,  especially  fat,  and  in  some  cases  the  concentrated  beef  and  alcoholic 
foods,  will  be  found  useful.  Syrups,  cod-liver  oil,  etc.,  are  very  apt  to  dis- 
turb the  appetite.  Butter  in  large  quantities,  for  those  who  can  afford  it, 
is  better  than  cod-liver  oil,  much  pleasanter,  and  less  liable  to  disturb  diges- 
tion. When  milk  is  distasteful,  its  'relish  can  be  cultivated  by  adding  a 
pinch  of  salt  or  by  feeding  the  child  a  bowl  of  bread  and  milk  daily,  a 
tablespoon  being  used,  so  that  the  mouthful  should  consist  of  a  large 
amount  of  milk,  not  merely  soaked  bread,  as  is  the  case  when  a  teaspoon 
and  small  cup  are  used. 


El  Tratamiento  al  aire  Libre  de  la  Tuberculosis  Quiriirgica. — (Willard.) 

En  la  tuberculosis  de  los  huesos  y  de  las  articulaciones,  lo  mismo  que 
en  los  casos  medicos,  la  vida  al  aire  libre,  de  dia  y  de  noche,  es  un  factor 
esencial  en  el  tratamiento. 

El  diagnostico  prematuro,  el  tratamiento  al  aire  libre,  los  rayos  del 
Sol,  aire  puro,  descanso  y  la  aplicacion  apropiada  de  los  procedimientos 
mecanicos  y  quiriirgicos,  puden  prevenir  y  aun  curar  sin  deformidad  una 
gran  parte  de  los  casos  de  enfermedades  de  las  articulaciones — 25,000  dosis 
de  aire  puro  en  24  horas  infinitamente  mejor  que  tres  dosis  de  una  droga 
que  produce  nauseas,  y  desarreglos  de  la  digestion. 

La  temperatura  baja  es  detrimental  al  bacilo.  El  frio  aumenta  el 
apetito,  la  nutricion  y  la  circulacion,  predispone  al  ejercicio  y  al  sueno,  dd 
buen  color,  aumenta  el  peso,  las  fuerzas  y  la  hemoglobina  de  la  sangre.  El 
cambio  de  las  orillas  del  mar  a  las  montafias  es  deseable;  90%  de  los  oasos 
de  las  afecciones  de  las  articulaciones  pertenecen  a  la  clase  pobre. 

Necesidad  de  separar  los  casos  de  tuberculosis  pulmonar  y  de  tuberculosis 
quirurgica  en  los  sanatorios  y  hospitales.  Construccion  de  los  sanatorios 
y  hospitales  de  un  modo  tal  que  las  camas  puedan  moverse  facilmente  dentro 
6  afuera  de  las  ventanas,  dando  asi  cuarto  caliente  para  las  operaciones  y 
cuidados  posteriores.  Asepsia  para  la  prevencion  de  las  infecciones  mixtas. 
La  afeccion  de  las  articulaciones  requiere  muletas  al  nivel  del  suelo.  Tiendas, 
calientes  en  el  Verano,  frias  en  el  Invierno.  Cuarteles  abiertos.  Porticos 
espaciosos  para  las  camas  conectados  con  cuartos  privados  6  con  las  salas  de 
los  hospitales — abiertos  en  el  Verano — con  vidrieras  en  el  Invierno — Ventanas 
grandes,  armadura  de  las  camas.  Litras  con  ruedas.  Biombos,  sombras; 
jardines  en  el  techo.  Tormentas.  Cabaiias  portatiles.  Campos  diurnos 
cerca  de  las  ciudades;  Escuelas  de  campo  para  los  pacientes  con  tendencias 


I 


OPEN-AIR   TREATMENT    OF    SURGICAL   TUBERCULOSIS. — WELL.ARD.        267 

hereditarias.  Tratamiento  en  el  hogar.  Ventanas  abiertas,  la  cabeza  fuera 
de  la  ventana — Proteccion  contra  el  frio,  papeles  debajo  de  los  colchones, 
ropa  suficiente,  buena  alimentacion,  cuidado  en  la  seleccion  de  las  condiciones. 
Casas  de  campo  insalubres. 


DISCUSSION. 

Dr.  John  M.  T.  Finney  (Baltimore)  said  the  Johns  Hopldns  Hospital 
had  been  a  pioneer  in  this  countiy  in  advocating  the  outdoor  treatment  of 
surgical  tuberculosis.  In  the  early  days  of  the  hospital  Dr.  Halsted  had 
insisted  in  keeping  these  cases  out  of  doors.  The  results  had  been  most 
satisfactory. 

Dr.  R.  W.  Corwin  (Pueblo,  Colorado)  believed  that  all  cases  should  be 
treated  in  the  open  air.  There  are  only  two  reasons  why  hospitals  for 
tuberculosis  have  not  been  taken  to  the  country,  and  these  are  ignorance 
on  the  part  of  municipal  authorities  and  because  doctors  were  too  lazy  to  go 
out  into  the  country. 

Dr.  Willard,  in  closing,  said  that  in  his  experience  lung  tuberculosis 
occasionally  occurred  after  tuberculosis  of  the  joints,  but  rarely.  The 
majority  of  his  fatal  cases  were  due  to  tuberculous  meningitis,  and  not  to 
secondary  lung  tuberculosis. 


TUBERCULOSIS  OF  THE  URINARY  TRACT. 

By  Thorkild  Rovsing,  M.D., 

Professor  of  Clinical  Surgery  at  the  University  of  Copenhagen. 


Remarks  on  the  Diagnosis. 

Tuberculosis  of  the  urinary  tract,  in  by  far  the  greatest  number  of  cases, 
proceeds  from  the  one  kidney,  and  the  chances  for  complete  recovery  in  such 
cases  of  surgical  means,  are,  as  a  rule,  the  best  possible,  provided  the  diag- 
nosis is  made  at  a  sufficiently  early  stage,  that  is,  before  the  tuberculosis  has 
spread  to  the  bladder  and  beyond.  But  the  diagnosis,  alas!  is  but  too  often 
made  at  an  exceecUngly  late  stage,  which  fact  will  be  brought  home  to  you 
when  I  tell  you  that  out  of  my  162  patients,  30  were  absolutely  too  far  gone 
for  operation  and  in  an  utterly  hopeless  condition,  and  that  no  less  than  42 
(39  per  cent.)  of  the  patients,  where  I  still  found  indication  for  nephrectomy, 
had  already  tuberculosis  in  the  bladder. 

What  are  the  causes  of  this  deplorable  fact?  In  a  certain  number  of 
cases  cystitic  symptoms,  as  a  matter  of  fact,  are  the  first  thing  which  show 
the  patient  that  he  is  ill  and  take  him  to  the  doctor,  and  under  these  cir- 
cumstances, therefore,  the  latter  is  blameless.  But  in  many  cases — about 
60  per  cent,  in  my  statistics — pains  in  the  region  of  the  kidneys,  emaciation, 
weariness,  turbidness  of  the  urine,  have,  long  before  the  bladder  symptoms 
set  in,  caused  the  patient  to  consult  a  doctor,  who  has  then  made  a  wrong 
diagnosis.  The  wrong  diagnosis  is  most  frequently  nephritis,  under  which 
diagnosis  many  of  my  patients  have  been  treated  for  a  lengthy  period,  even 
by  clever  doctors  and,  worse  still,  in  medical  hospital  wards.  In  the  urine, 
which  is  often  but  very  slightly  turbid,  the  ordinary  chemical  tests  show  a 
faint  or  medium  albumin  reaction,  which  is  diagnosed  as  arising  from  a 
nephritis,  and  a  rigorous  diet — milk,  milk  foods,  and  fish  are  then  ordered — 
a  fatal  mistake,  especially  here,  because  the  patient's  power  of  resisting  the 
tuberculosis  is  materially  weakened  by  this  protracted  scanty  fare,  and  the 
disease  advances  rapidly. 

Then  there  are  cases  where  the  urine  contains  visible  pus  and  where  the 
diagnosis  is  pyelitis,  and  the  patient  is  then  treated  with  salol,  boric  acid,  or 
similar  remedies.  But  even  the  appearance  of  cystitic  symptoms  does  not 
by  any  means  always  bring  the  doctor  on  the  right  track;  the  only  result  is 
that  he  often,  without  a  more  thorough  examination  as  to  what  form  of 
cystitis  he  has  here  to  deal  with,  blindly  attacks,  so  to  speak,  the  disease 

268 


TUBERCULOSIS   OF  THE   URINARY  TRACT. — ROVSING.  269 

with  the  ordinary  cystitic  remedies,  such  as  lapis  instillations,  which  are 
exceedingly  painful,  entirely  useless,  and  often  apparently  aggravate  the 
cystitis.  These  patients  are  in  a  still  worse  plight  if,  a  short  time  previously, 
they  have  been  suffering  from  gonorrheal  urethritis,  because  the  cystitis 
is  then  taken  to  be  gonorrheal  and  treated  with  protargol  or,  what  is  still 
worse,  with  the  Janet  daily  lavage  with  a  solution  of  permanganate  of 
potash,  which  appears  to  have  a  particularly  injurious  effect  upon  the 
mucous  membrane  of  a  tuberculous  bladder;  this  treatment,  in  any  case, 
appears  to  have  had  a  fatal  influence  in  two  of  my  cases. 

All  these  regrettable  erroneous  diagnoses  might  be  avoided  if  only  doctors 
fully  realized  that  one  ought  never  to  begin  the  treatment  of  albuminuria, 
P3airia,  or  cystitis  without  first  having  subjected  the  urine,  sterilely  taken 
from  the  bladder,  not  only  to  a  chemical,  but  also  to  a  microscopical  and 
bacteriological,  examination. 

I  am  quite  aware  that  it  is  maintained  to  be  very  difficult  to  prove  the 
presence  of  tubercle  bacilli.  Even  in  the  newest  hand-books,  such  as  Kiis- 
ter's  and  Wagner's,  it  is  stated  that,  to  show  the  presence  of  tubercle  bacilli 
in  diseases  of  the  urinal  charmel  only  succeeds  in  10  to  20  per  cent,  of  the 
cases.  With  reference  to  these  statements  I  can  only  say  that  the  gentlemen 
in  question  must  have  adopted  unfortunate  methods  or  have  not  persevered 
long  enough,  for  when  I  make  up  the  statistics  from  all  my  cases,  it  appears 
that  the  presence  of  tubercle  bacilli  has  been  successfully  shown  in  80.7 
per  cent,  of  these  cases.  The  method  which  I  have  used  with  such  good 
results  is  that  of  Forsell,  according  to  which  one  lets  the  aggregate  urine  of 
the  twenty-four  hours  precipitate  in  a  separatory.  The  lowest  portion  of 
the  precipitate  which  contains  the  tubercle  bacilli  is  separated  and  can  then, 
in  addition,  be  centrifugally  treated  before  being  examined  microscopically. 

For  a  practitioner  all  such  circumstantial  methods,  as  a  rule,  are  entirely 
unnecessary,  for  simple  microscopy  with  ordinary  microbe  coloring  is  suf- 
ficient to  give  him  the  diagnosis :  if  he  finds  pus  in  the  urine  but  no  microbes, 
the  diagnosis  of  tuberculosis  is  almost  certain;  the  case  is  anyhow  so  suspi- 
cious that  the  patient  must  at  once  be  sent  to  a  place  where  a  special  ex- 
amination by  experts  can  be  undertaken;  for  in  all  suppurative  kidney 
affections  we  find  numerous  easily  colored  microbes  in  the  urine. 

When  we  are  certain,  or  at  any  rate  have  a  strong  suspicion,  that  it  is 
a  case  of  tuberculosis  of  the  urinary  organs,  it  is  necessary  for  us  accurately 
to  define  the  seat  and  the  extent  of  the  tuberculosis.  Is  the  bladder  tuber- 
culous, and  if  so,  by  ascending  or  descending  infection?  But  the  question 
as  to  what  should  be  our  principal  method  of  deciding  these  vital  points  is 
a  subject  of  strong  disagreement  among  medical  men  all  over  the  world,  as 
Luys'  and  Cathelin's  so-called  urine  segregators  are  being  advocated  in 
preference  to  cystoscopy  and  ureter  catheterization. 


270  SIXTH   I>fTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

The  use  of  ureter  catheterization,  more  especially  in  tuberculosis  of  the 
urinal  organs,  has  many  enemies,  no  doubt  principally  on  account  of  the  art 
of  ureter  catheterization  being  so  difhcult  to  learn,  and  requiring  so  much 
time,  but  also  because  one  is  afraid  of  infecting  the  possibly  sound  ureter, 
and  even  if  we  maintain  that  this  risk,  as  far  as  experience  shows  us,  is  very 
slight,  yet  its  existence  camiot  be  denied,  and  it  would  be  desirable  if  we  could 
manage  with  cystoscopy  alone  or  with  segregators.  According  to  my 
experience,  this,  however,  is  entirely  impossible,  and  with  your  permission 
I  will  lay  my  proofs,  which  you  will  find  in  the  graphic  diagrams  of  the  cases 
complicated  with  bladder  tuberculosis,  before  you.  Cystoscopy  pure  and 
simple  is  always  uncertain;  in  some  cases  we  can,  of  course,  see  undoubtedly 
purulent  urine  flow  from  the  orifice'  of  the  ureter  and  thus  obtain  tolerable 
certainty  of  the  kidney  in  question  being  affected,  but  we  are  then  left 
entirely  in  the  dark  as  to  the  state  of  the  other  kidney,  for  a  macroscop- 
ically  clear  urine  is  not  by  any  means  synonymous  with  a  normal  urine. 
Cystoscopy,  generally  speaking,  should  enlighten  us  about  alterations  in 
the  shape  of  the  orifice  of  the  ureter,  swellings,  miliary  tubercles,  and  ulcer- 
ation around  the  diseased  orifice  of  the  ureter.  But  if  you  will  be  good 
enough  to  look  at  this  table,  where  every  case  is  represented  by  a  drawing 
which  shows  the  area  of  the  tuberculosis  in  the  urogenital  organs,  you 
will  find  that  the  tuberculous  alterations  in  the  bladder  in  only  a  minority 
of  the  cases  are  localized  around  the  diseased  ureter.  In  some  cases  you  will 
see  that  the  bladder  tuberculosis,  in  a  directly  misleading  manner,  has  local- 
ized exclusively  round  the  orifice  of  the  sound  ureter,  as  in  cases  18,  42,  47. 
You  will  find  cases  where  both  the  kidneys  are  affected,  but  both  the  ureteric 
orifices  are  free  from  alterations,  or  where  the  tuberculosis  has  localized 
around  the  orifice  of  the  one  ureter,  but  in  by  far  the  gTeatest  number  of 
cases  you  will  see  that  bladder  tuberculosis  in  one-sided  kidney  affection  is 
spread  over  both  sides  or  halves  of  the  bladder,  sometimes  over  the  whole  of 
the  mucous  membrane  of  the  bladder  (see  cases  Nos.  5,  6,  13,  18,  21,  24,  26, 
29,  30,  41,  43,  44,  48,  49,  50,  51,  52,  53,  54,  and  56). 

But  if  this  capricious  spreading  of  the  bladder  tuberculosis  makes  the 
deductions  which  you  can  draw  from  simple  cystoscopy  most  unreliable,  its 
effect  upon  the  results  obtainable  by  means  of  Luys'  and  Cathelin's  segre- 
gators are  still  more  fatal,  for  it  is  a  matter  of  course  that  in  all  those  cases 
of  one-sided  kidney  tuberculosis  with  an  opposite  or  extended  localization 
of  bladder  tuberculosis  purulent  urine  containing  tubercle  bacilli  will  be 
drawn  from  both  the  tubes  of  the  segregator,  and  thus  wrongfully  lead  to 
the  diagnosis  of  double  kidney  tuberculosis,  where  in  reality  it  is  a  case  of 
only  one-sided  kidney  tuberculosis.  This  is  the  more  serious  because  this 
mistake  will  never  be  brought  to  light  to  a  doctor  depending  upon  the 
segregator,  for  the  patient  will  be  sent  away  as  unfit  for  operation,  and  when 


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Tuberculosis  of  the  riiiiary  Tract  (Hovsiug). 
B,  Better.      H,  Healed.     C",.  Carbolic  treatment.     S,  Spontaneous.     K,  Extirpation. 


TUBERCULOSIS   OF   THE   URINARY   TRACT. — ROVSING.  271 

in  due  course  he  succumbs  to  his  disease,  it  only  seems  to  confirm  the 
erroneous  diagnosis.  Thus  by  using  this  method  we  run  the  risk  that  a 
certain  number  of  patients  who  could  have  been  saved  by  nephrectomy 
are  left  to  their  fate. 

Therefore  this  method  ought  not  to  be  allowed  to  take  the  place  of,  or 
be  put  on  a  level  with,  the  ureter  catheterization,  which  is  the  only  bloodless 
method  which  can  give  us  certain  knowledge  of  the  state  of  the  Iddneys,  and 
it  is  necessary  to  warn  against  the  use  of  segregators  which  are  so  tempting 
because  of  the  technical  simplicity  of  the  method  which  any  one  can  apply, 
while  ureter  catheterization  requires  special  training  and  practice. 

The  examination  of  the  urine  taken  from  each  kidney  must  be  under- 
taken with  great  care  and  judgment;  it  must  be  subjected  to  a  thorough 
chemical,  microscopical,  and  bacteriological  examination.  If  we  were  to 
content  ourselves  with  a  chemical  analysis  of  the  urine  from  each  kidney  for 
albumin,  we  might  in  some  cases  be  led  to  suppose  we  had  a  case  of  double- 
sided  kidney  tuberculosis  where,  in  reality,  it  was  only  one-sided.  It  is  of 
less  importance  that  an  albumin  reaction  can  be  owing  to  a  mixture  of  blood 
in  the  otherwise  normal  urine  caused  by  a  traumatic  injury  to  the  mucous 
membrane  by  the  point  of  the  catheter,  because  in  most  cases  one  will 
obsei've  the  sudden  blood  color  in  the  urine,  but  in  order  to  make  certain  that 
the  bleeding  has  not  been  caused  by  the  ulcerated  state  of  the  mucous  mem- 
brane, the  urine  must  be  subjected  to  careful  microscopical  examination.  It 
is  of  greater  importance  to  know  that  with  severe  tuberculosis  of  the  one 
kidney  one  can  have  real  albuminuria  from  the  other,  without  this  signifying 
that  the  latter,  too,  is  tuberculous.  In  this  instance  it  is  a  case  of  toxic 
albuminuria  which  is  caused  by  the  blood  having  absorbed  poisonous  sub- 
stances from  the  tuberculous  kidney,  and  as  such  toxic  albuminuria,  instead 
of  counterindicating  an  operation,  requires,  on  the  contrary,  a  speedy 
extirpation  of  the  tuberculous  kidney  from  which  the  poisoning  proceeds, 
it  will  be  easily  apparent  how  important  it  is  to  be  able  to  discern  between 
the  former  and  the  albuminuria  which  mdicated  the  commencement  of 
tuberculosis  in  the  other  kidney.  This  can  only  be  done  by  careful  micro- 
scopic and  bacterioscopic  examination  of  the  albuminous  urine.  If  tliis 
does  not  contain  any  or  only  contains  very  few  leukocytes  and  no  bacilli, 
then  we  have  to  deal  with  a  toxic  albuminuria,  while  a  real  tuberculous 
kidney  affection  will  always  show  numerous  leukocytes  and  most  frequently 
easily  discernible  tubercle  bacilli,  for  the  more  recent  the  tuberculous  affec- 
tion, the  more  numerous  the  bacilli.  At  the  congress  of  surgeons  held  in 
Berlin  in  April,  1905,  I,  for  the  first  time,  drew  attention  to  the  importance 
of  this  diagnosticating  toxic  albuminuria,  and  in  my  introductory  address 
to  the  discussion  on  nephrectomy  in  kidney  tuberculosis,  I  mentioned  five 
such  cases  where  I,  in  spite  of  a  fairly  pronounced  albuminuria  from  the 


272  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

other  kidney,  had  extirpated  the  tuberculous  kidney,  and  afterward  seen 
the  albuminuria  disappear  in  the  course  of  a  very  short  time,  the  patients 
being  cured.  To  this,  from  subsequent  personal  experience,  I  can  add  six 
new  cases,  and  Albarran  has  recently  published  some  cases  of  a  similar 
nature. 

These  cases  show  better  than  anything  else  the  supremacy  of  ureter 
catheterization  from  a  diagnostic  and  prognostic  point  of  view,  but,  un- 
fortunately, there  are  cases  where  this  examination  is  confronted  with 
insurmountable  obstacles,  and  this  is  more  especially  the  case  where  the 
bladder,  too,  is  attacked  by  tuberculosis.  In  the  first  place  the  irrita- 
bility of  the  bladder  with  widespread  ulcerated  cystitis  can  be  so  great 
that  cystoscopy  is  altogether  impossible,  as  the  bladder  cannot  contain  the 
necessary  quantity  of  fluid.  Secondly,  there  are  cases  where  cystoscopy 
would  otherwise  be  practicable  were  not  the  ureteric  orifices  so  buried  in 
ulcerations  and  swellings  that  it  is  impossible  to  insert  the  catheter.  A 
valuable  aid  in  finding  the  mouths  of  the  ureter  in  such  cases  is  Voelker's 
so-called  chromocystoscopy,  the  indigo-carmin  colored  urine  showing  us  the 
way,  but  the  ureter  catheter  is  often  stopped  at  once  or  a  little  inside  the 
mouth  by  a  stricture  which  thus  prevents  us  from  obtaining  urine.  In 
about  one-third  of  the  cases  complicated  by  bladder  tuberculosis  I  have 
been  obliged,  for  these  reasons,  to  abandon  ureter  catheterization.  In  not 
a  few  cases  this  method  of  examination  fails  even  for  an  experienced  cys- 
toscopist.  Shall  we  then  leave  such  patients  to  their  uncertain  fate,  or  have 
we  other  means  of  preventing  surgeons  from  committing  the  surgical  error  of 
extirpating  the  one  kidney  when  the  other  is  also  attacked  and  functionally 
incompetent?  In  my  opinion,  there  is  only  one  fairly  reliable  means  of 
attaining  these  ends,  namely,  my  double  explorative  lumbar  incision  brought 
out  in  the  year  1894,  by  which,  at  the  same  seance,  I  lay  bare  both  kidneys 
and  subject  them  to  a  thorough  inspection  and  palpation.  If  I  find  the  one 
kidney,  or  possibly  the  ureter,  much  affected  by  tuberculosis,  while  the  other 
kidney  and  ureter  show  normal  conditions  to  the  touch  and  the  eye,  I  can 
with  confidence  extirpate  the  tuberculous  kidney,  for  even  if  this  examina- 
tion does  not  to  a  certainty  exclude  the  presence  of  a  small  tuberculous  focus 
in  the  apparently  sound  kidney,  one  can  make  sure  of  its  being  capable  of 
function.  Under  such  circumstances  it  is  always  of  great  importance  to  draw 
forward  the  ureter  on  a  finger  for  a  minute  examination,  for  in  cases  of 
ascending  tuberculosis  the  kidney  may  still  be  quite  sound  both  to  the  touch 
and  the  eye — it  is  only  the  enlarged  and  distended  ureter  which  betrays  the 
presence  of  the  disease. 

The  double  lumbar  incision  has  been  used  by  me  in  22  cases,  and  I  have 
never  lost  a  patient  by  this  method.  In  14  cases  I  ascertained  the  one- 
sidedness  of  the  disease,  which  could  not  have  been  ascertained  by  any 


TUBEKCULOSIS    OF   THE   URINARY   TRACT. — ROVSING.  273 

Other  means.  I  removed  the  diseased  kidney,  and  in  all  cases  recovery  was 
the  result.  In  8  cases  I  ascertained  the  double-sidedness  of  the  disease;  in 
5  of  these  I  closed  again  without  proceeding  further.  In  2  cases  I  undertook 
ureterostomy  to  procure  relief  from  pains  and  to  arrest  the  process  of  as- 
cending tuberculosis;  in  1  case  I  punctured  an  abscess  in  the  kidney  as 
large  as  a  hen's  egg. 

It  may  have  surprised  you  that  I  have  not  so  far  touched  upon  the  im- 
portance of  the  different  so-called  kidney-function  examinations  for  ascer- 
taining the  condition  of  the  other  kidney  prior  to  nephrectomy.  My  reason 
is  that  many  years'  experience  and  examinations,  for  which  I  and  my 
assistant,  Dr.  Koch,  have  fully  accounted  in  previous  publications,  have 
shown  me  that  nothing  reliable  can  be  based  upon  these  examinations,  be- 
cause the  capacity  of  the  kidney  cannot  at  all  be  gaged  by  the  work  of 
secretion  done  at  the  moment,  and  which  is  dependent  upon  a  number  of 
factors. 

I  have,  ever  since  1892,  systematically  undertaken  quantitative  analyses 
of  urea  with  all  my  kidney  patients  prior  to  operation,  and  found  that  a  nor- 
mal secretion  of  urea  is  a  safe  criterion  of  a  sufficiency  of  kidney  tissue 
capable  of  function,  but  that,  on  the  other  hand,  nothing  can  be  gath- 
ered from  a  reduced  secretion,  inasmuch  as  the  latter  directly  or  indirectly 
can  be  owing  to  the  diseased  kidney — directly,  by  a  purely  reflex  effect 
upon  the  secretion  of  the  sound  kidney  (reno-renal  reflex) ;  indirectly,  by  the 
disease  actuating  the  functions  of  the  whole  organism.  I  have  shown  tliis 
in  a  whole  series  of  cases  in  which  the  secretion  of  urea,  after  the  removal  of 
the  tuberculous  kidney,  from  being  minimal  quickly  rose  to  a  normal  height. 
While  a  normal  secretion  of  urea  imparts  a  very  important  and  satisfactory 
knowledge,  it  is,  on  the  other  hand,  veiy  risky  to  adduce  from  a  slighter 
secretion  of  urea  that  both  kidneys  are  inadequate.  This  may  serve  as  a 
warning  to  proceed  cautiously,  but  nothing  beyond  that. 

With  regard  to  all  the  rest  of  modern  kidney-function  examinations,  I 
have  shown  that  these  are  still  more  unreliable  than  the  urea  analysis,  for 
while  the  latter  only  misleads  by  a  negative  result,  both  chromocytoscopy 
(Achard's  methylene-blue  test,  Voelker's  indigo  carmin),  cryoscopy,  and  the 
phloridzin  method  are  capable  of  misleading  by  positive  as  well  as  negative 
results.  I  have,  therefore,  entirely  given  up  these  artificial  and  compUcated 
methods  in  favor  of  the  simple  and  rational  quantitative  urea  analysis,  which 
I  make  by  the  aid  of  Esbach's  ureometer. 

Prognosis  and  Treatment. 
The  great  change  in  our  conception  of  the  pathogenesis  of  the  disease,  to 
which  I  have  referred,  and  the  great  advance  we  have  made  in  diagnostic 
skill,  have  also  caused  a  happy  change  in  the  treatment  of  urogenital  tuber- 


274  SIXTH    INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

culosis  and  its  prognosis.  Tlie  old  pessimistic  conception  of  the  prognosis 
and  the  consequent  passive  position,  therapeutically,  has  given  place  to  a 
more  hopeful  prognosis. 

If  we  should  define  the  status  of  the  question  at  the  present  moment,  I 
consider  that,  generally  speaking,  I  can  maintain  that  the  possibility  of  a 
radical  cure  is  dependent  on  two  conditions:  first,  that  the  point  where  the 
tuberculosis  originates  within  the  urogenital  organs  can  be  radically  removed; 
and,  second,  that  at  least  the  one  kidney  is  sound. 

As  far  as  the  descending  tuberculosis  of  the  urinary  tract  is  concerned, 
these  two  conditions,  of  course,  go  together:  if  only  the  one  kidney  is  at- 
tacked, there  are  chances  for  a  cure  by  nephrectomy.  With  ascending 
urogenital  tuberculosis  both  conditions  have  to  be  reckoned  with,  inasmuch 
as  the  tuberculosis  here  originates  in  the  genital  organs,  but  often  secondarily 
spreads  to  the  Iddneys.  This  doubly  complicated  condition  makes  the  pros- 
pects of  a  cure  considerably  slighter  with  ascending  urogenital  tuberculosis. 
As  I,  in  my  introductory  remarks,  had  the  opportunity  of  proving  from  my 
material,  the  prognosis  for  ascending  urogenital  tuberculosis  is  in  reality 
much  slighter  than  for  descending.  This  is  partly  owing  to  the  fact  that 
while  primary  Iddney  tuberculosis  in  the  great  majority  of  cases  is  one-sided, 
secondary  kidney  tuberculosis  is  just  about  as  often  double-sided  as  one- 
sided, and  partly  to  the  desperate  course  which  a  breaking  through  of  the 
tuberculosis  from  the  prostate  to  the  bladder  and  urethra  most  frequently 
takes,  attended  by  uroplany  extravasation,  fistula  formations,  etc. 

If,  on  the  other  hand,  only  the  epididymis,  vas  deferens,  and  a  single 
kidney  are  attacked,  there  is  every  prospect  of  a  cure  through  the  removal  of 
the  epididymis  and  the  diseased  kidney,  even  if  the  bladder  should  be  also 
attacked.  This  latter  complication,  up  to  a  few  years  ago,  was  considered 
so  serious  that  it  was  looked  upon  as  an  absolute  counterindication  against 
operation.  We  know  now,  through  numerous  instances,  that  a  slight  bladder 
tuberculosis  is  frequently  cured  spontaneously  when  the  original  focus  is 
removed,  but  even  with  extensive  bladder  tuberculosis,  which  excludes  a 
spontaneous  cure,  there  is  every  chance  of  bringing  about  a  cure  by  treat- 
ment with  6  per  cent,  solution  of  carbolic  acid,  with  which,  up  to  the  present 
time,  I  have  cured  24  patients. 

In  all  the  cases  where,  by  means  of  the  diagnostic  aids  which  I  have  just 
described,  I  have  proved  that  only  the  one  kidney  was  attacked,  I  have  re- 
moved it  by  nephrectomy.  All  told,  I  have  performed  106  nephrectomies 
for  kidney  tuberculosis  with  but  6  deaths,  that  is,  5.7  per  cent,  mortality. 
There  were  2  deaths  in  the  first  14  cases,  which  were  performed  before  1901, 
consequently  14.2  per  cent.  mortaUty,  while  there  were  only  4  deaths  out 
of  the  91  nephrectomies  performed  after  1901 — that  is,  4.3  per  cent.  Con- 
sidering how  exceedingly  far  advanced  the  disease  was  in  the  majority  of 


TUBERCULOSIS   OF   THE   URINABY  TRACT. — ROVSING.  275 

these  cases,  I  think  we  may  look  upon  this  as  a  very  low  mortality,  and  as  I 
am  of  the  opinion  that  this  result  is  owing  to  the  method  according  to  which 
I  have  invariably  operated  during  the  last  seven  years,  a  short  description 
of  this  method  may  be  of  interest  to  you.  JNIy  principle  is  to  remove  the 
kidney  as  a  closed  whole,  so  that  no  tuberculous  virus  can  have  a  chance  of 
infecting  the  lumbar  incision.  I  use  an  amply  slanting  lumbar  incision, 
open  the  fat  casing  of  the  kidney  at  the  back,  loosen  mth  great  care  by 
means  of  my  rubber-gloved  hand  the  kidney  from  its  bed  and  possible  ad- 
hesions, examine  and  palpate  it  minutely  in  order  to  verify  the  diagnosis, 
then  ch-aw  the  ureter  forward  on  my  bent  left  forefinger,  tie  it  up  in  two 
places  with  strong  silken  thread,  in  order  slowly  to  burn  it  through  with 
red-hot  thermocautery  between  the  silk  threads,  about  3  centimeters  beneath 
the  entrance  into  the  pelvis.  I  then  isolate  this  from  the  vessels  in  the  ped- 
icle, which  is  tied  up  with  strong  formalin  catgut,  after  which  the  kidney  is 
removed  by  cutting  through  the  vessels.  The  peripheral  end  of  the  ureter 
is  fastened  to  the  skin  1  centimeter  from  the  wound-line,  whereby  I  insure 
against  any  possibility  of  infection  from  tuberculosis.  Formerly,  when  I 
removed  as  much  of  the  ureter  as  possible  and  lowered  the  stump,  the  latter 
often  became  the  starting-point  for  an  exceedingly  dangerous  diffused  tu- 
berculosis in  the  retroperitoneal  tissue  and  in  the  abdomen. 

In  case  one  or  both  the  epididymides  are  attacked,  an  extirpation  of  the 
epididymis  is  performed  at  the  same  or  a  subsequent  seance,  with  the  pres- 
erv'^ation  of  the  testis  if  the  latter  be  not  attacked.  The  severed  vas 
deferens  is  treated  as  was  the  ureter:  it  is  sewTi  forward  to  the  scrotal 
skin,  where  it,  when  the  sore  is  otherwise  healed,  is  kept  open  as  a  safety 
valve  for  the  tuberculous  secretion,  which  might  be  in  the  peripheral 
parts  and  in  the  vesiculse  seminales.  I  have  adopted  this  method  in  con- 
nection with  nephrectomy  in  21  cases,  and  always  with  good  results.  If 
there  is  tuberculosis  of  the  bladder,  I  wait  some  time  after  the  nephrectomy 
to  see  whether  the  bladder  tuberculosis  will  heal  spontaneously,  which  I 
ascertain  by  every  fourteen  days  performing  cystoscopy.  In  14  cases  spon- 
taneous healing  resulted  simply  in  consequence  of  the  source  of  the  in- 
fection having  been  removed  with  the  kidney.  But  in  the  remaining  25 
cases  there  was  no  such  spontaneous  healing.  Sometimes,  contrary  to 
what  is  generally  the  case,  quite  a  small  tuberculosis  was  seen  to  spread, 
assuming  a  very  vicious  character,  but  in  these  cases  the  bladder  tubercu- 
losis was,  as  a  rule,  already  far  advanced  when  the  patient  came  into  the 
hospital.  These  cases  I  have  subjected  to  local  treatment  with  6  per  cent, 
carbolic  acid  solution.  This  treatment,  which,  to  begin  with,  is  under- 
taken every  other  day,  consists  in  first  rinsing  the  bladder  with  sterilized 
water  and  then  making  an  injection  of  50  c.c,  freshly  made,  warm,  6  per 
cent,  carbolic  solution;  tliis  is  allowed  to  remain  for  two  to  three  minutes  and 


276  SIXTH   INTERNATIONAL    CONGRESS   ON  TUBERCULOSIS. 

comes  away  as  a  perfectly  milky  fluid.  These  injections  are  continued  until 
the  carbolic  water  comes  away  fairly  clear.  The  effect  of  this  treatment, 
which,  as  a  rule,  manifests  itself  quickly,  is  shown  by  the  cessation  of 
the  pus  secretion  and  the  urine  becoming  clearer.  By  degrees,  as  the  urine 
becomes  clearer,  the  injections  are  made  at  longer  and  longer  intervals 
and  cease  when  it  has  been  shown  by  cystoscopy  that  the  mucous  mem- 
brane of  the  bladder  is  healed.  This  we  can  see  by  the  ulcerations  in 
the  cystoscopic  picture  being  replaced  by  smooth  mother-of-pearl  like 
cicatricial  tissue.  With  widespread  tuberculosis  a  six  to  eight  weeks' 
treatment  is,  on  an  average,  necessary.  If  the  patient  and  the  doctor  have 
the  perseverance  to  carry  through  the  treatment,  a  cure  is  certain,  subject 
to  two  conditions:  (1)  that  the  source  of  infection  is  removed,  and  (2)  that 
the  tuberculosis  is  confined  to  the  mucous  membrane  and  has  not  spread 
through  "the  walls  of  the  bladder.  It  is  only  subject  to  these  conditions  that 
the  adoption  of  this  treatment  can  be  at  all  recommended.  The  first  patient 
treated  in  this  way,  and  in  whose  case  the  tuberculosis  was  of  an  unusually 
vicious  nature,  and  extending  over  the  whole  of  the  bladder,  has  now  been 
well  for  five  years.  A  drawback  to  tliis  method  is  the  considerable  amount 
of  pain  which  it  entails;  but  one  can  materially  ameliorate  the  pain  by 
injecting  cocain  or  eucain  into  the  bladder,  and,  after  the  washing,  giving 
the  patient  a  suppository  with  opium  or  morphin.  I  have  only  seen  isolated 
cases  of  carbolic  poisoning:  black  urine,  nausea  and  vomiting,  but  these 
symptoms  quickly  subsided.  When  it  is  made  plain  to  the  patient  that 
tliis  treatment  is  the  only  chance,  and  at  the  same  time  a  very  great  chance, 
of  saving  life  and  health,  he,  as  a  rule,  submits  patiently  to  the  pain. 

I  have  of  late  gone  still  further  in  my  attempts  to  save  apparently  hope- 
less patients,  as,  for  instance,  in  the  case  I  have  already  mentioned  while 
speaking  about  the  diagnosis,  where  the  double  lumbar  incision  showed  me 
that  the  tuberculosis  had  proceeded  from  the  completely  destroyed  left 
kidney,  through  the  ureter,  spread  to  the  bladder,  the  mucous  membrane 
of  which  was  completely  ulcerated,  and  from  there  had  again  ascended  to 
the  right  ureter  and  there  produced  stricture  and  distention.  In  this  case 
I  performed  extirpation  of  the  left  kidney  and  lumbar  ureterostomy  on  the 
right  side ;  by  doing  tliis  I  prevented  the  tuberculosis  from  ascending  to  the 
other  kidney,  which  was  still  sound ;  I  kept  the  fistula  open  until  I  had  cured 
the  bladder  tuberculosis  by  carbolic  treatment  and  widened  the  ureter 
stricture.  The  passage  through  the  ureter  was  then  reestablished,  and  the 
patient  is  still,  two  years  after  the  operation,  living  and  free  from  pains  of 
the  bladder,  the  right  kidney  officiating  satisfactorily. 

As  a  palliative  operation  I  use  and  strongly  recommend  ureterostomy  in 
cases  of  double-sided,  ascending  kidney  tuberculosis,  where  stricture  with 
distention  of  the  ureter  and  pelvis  causes  great  pain.     In  such  cases  we  not 


TUBERCULOSIS   OF   THE   URINARY  TRACT. — ROVSING.  277 

only  relieve  the  patient  completely  from  pain,  but,  by  establishing  a  free 
outlet,  arrest  the  upward  progress  of  the  tuberculosis,  and  the  patient's  life 
is  prolonged.  Neither  is  it  probably  altogether  out  of  the  question  that,  at 
an  early  stage,  an  ascending  kidney  tuberculosis  can  be  cured  in  this  manner. 
Formerly  I  used  a  catheter  or  drain  introduced  into  and  fixed  in  the  ureter, 
and  wliich,  through  the  bandaging,  was  carried  to  a  concave-convex  bottle 
v/hich  was  tied  to  the  lumbar  region  by  a  belt,  but  the  frequent  escape  of  the 
urine  by  the  side  of  the  catheter  and  the  drawbacks  resulting  therefrom  led 
me  to  construct  a  bandage  consisting  of  a  small  silver  capsule  fitted  with  a 
rubber  ring,  and  which,  by  means  of  an  elastic  girth  around  the  abdomen, 
is  kept  tight  around  the  ureter  fistula,  and  from  which  a  small  silver  tube 
through  a  drain  leads  the  urine  into  a  urinal. 


Tratamiento  de  la  Tuberculosis  Renal. — (Rovsing.) 

1.  El  peligro  de  infeccion  por  la  orina  tuberculosa  no  se  estima  bien  6 
se  descuida. 

2.  El  diagnostico  de  tuberculosis  renal  es,  como  regla  general,  hecho 
despues  de  muchos  afios  de  enfermedad  y  solo  cuando  la  vejiga  ha  sido 
afectada. 

3.  Hasta  que  aparecen  los  sintomas  de  la  vejiga,  el  diagnostico  es 
nefritis,  y  el  tratamiento  por  tanto  enteramente  diferente  de  la  terapeutica 
racional. 

4.  La  atencion  de  los  medicos  debe  concentrarse  a-  hacer  un  pronto 
diagnostico  por  el  examen  microscopico  y  bacterologico  de  la  orina  en  caso 
de  albuminuria. 

5.  Si  se  encuentra  pus,  sin  bacteria  en  manchas,  preparaciones  y  cul- 
tura,  el  diagnostico  de  tuberculosis  es  casi  seguro. 

6.  Hecho  el  diagnostico  debe  tenerse  cuidado  de  la  ropa  y  la  orina 
por  sus  propiedades  contagiosas. 

7.  Los  pacientes  deben  ser  enviados  a  un  circujano  para  la  cistoscopia 
y  la  uretral  cateterizacion,  pues  siempre  hay  una  probabilidad  de  cura  si 
un  rinon  esta  bueno;  por  nefrectomia  del  rinon  enfermo,  y  si  la  vejiga  esta 
tambien  afectada,  puede  tratarse  con  inyecciones  de  5  per  cent.-6  per  cent, 
de  solucion  de  acido  carbolico,  segun  mi  m^todo. 


Traitement  de  la  tuberculose  r€nale. — (Rovsing.) 
1.  Le  danger  d'infection  par  I'urine  tuberculeuse  est  trop  peu  estim6 
ou  neglige. 


278  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

2.  En  general  le  diagnostic  de  tuberculosa  renale  n'est  fait  qu'apr^s 
plusieurs  annees  de  maladie,  quand  la  vessie  commence  a  souffrir. 

3.  Avant  I'apparence  de  symptomes  vesicales  la  maladie  est  meconnue; 
le  medecin  diagnostique  une  nephrite,  et  par  consecjuent  le  traitement  qui 
est  suivi  est  tout  different  du  traitement  rationnel. 

4.  Necessite  d'attirer  Tattention  des  medecins  a  I'importance  d'une 
diagnose  precoce  a  I'aide  d'examen  microscopique  et  bacteriologique  des 
urines,  qui  devrait  se  faire  dans  tous  les  cas  d'albuminurie. 

5.  Si  les  urines  contiennent  du  pus,  sans  qu'on  trouve  des  bacilles  h, 
I'aide  de  I'examen  microscopic|ue  et  bacteriologique,  la  tuberculose  est 
presque  certaine. 

6.  Vu  le  danger  de  contagion  par  les  urines,  surveiller  celles-ci  et  le 
linge  du  malade  des  que  la  diagnose  a  ete  etablie. 

7.  Envoyer  le  malade  au  cliirurgien  pour  la  cystoscopie  et  la  catheterisa- 
tion  des  ureteres,  puisque  la  guerison  est  toujours  possible,  pourvu  que  Tun 
des  deux  reins  est  sain,  par  la  nephrectomie  du  rein  malade.  Si  la  vessie 
est  prise,  pratiquer  des  injections  de  solutions  de  phenol,  a  titre  de  5  ^  6 
pour  cent,  selon  la  methode  de  I'auteur. 


Die  Eehandlung  der  PTIerentuberkulose. — (Rovsing.) 

1.  Die  Gefahr  der  Infektion  durch  tuberkulosen  Urin  wird  unterschatzt 
oder  vernachlassigt. 

2.  Die  Diagnose  der  Nierentuberkulose  wird  gewohnlich  nur  nach 
jahrelanger  Krankheit  gemacht,  nachdem  die  Blase  affizirt  ist. 

3.  Bis  die  Blasensymptome  einsetzen,  ist  die  Diagnose  Nephritis,  und 
die  Behandlung  daher  von  der  rationellen  Therapie  ganz  verschieden. 

4.  Die  Aufmerksamkeit  des  Arztes  soil  daher  auf  die  friihe  Diagnose 
gelenkt  werden,  durch  mikroskopische  und  bakteriologische  Untersuchung 
des  Urins  in  jedem  Falle  von  Albuminuric. 

5.  Wenn  Eiter  gefunden  wird,  und  Bakterien  in  den  gefiirbten  Pra- 
paraten  und  in  Culturen  vorgefunden  v/erden,  dann  ist  die  Diagnose  auf 
Tuberkulose  nahezu  sicher. 

6.  Sobald  man  die  Diagnose  gestellt  hat,  muss  auf  die  Bettwasche  und 
den  Urin  achtgegeben  werden,  da  sie  ansteckend  sind. 

7.  Die  Patienten  sollten  einem  Chirurgen  fiir  die  Cystoskopie  und  Kathe- 
terisierung  der  Harnleiter  zugeschickt  werden,  da  sie  immer  Aussicht  haben, 
geheilt  zu  werden  durch  Nephrektomie  der  erkrankten  Niere,  wenn  eine 
Niere  gesund  ist;  und  wenn  die  Blase  audi  affizirt  ist,  kann  diese  durch 
Ausspiilangen  mit  einer  5  Procent  bis  6  Procent  Carbolsaurelosung  nach 
meiner  I\Iethode  behandelt  werden. 


TUBERCULOSIS  OF  MUSCLES,  TENDONS,  AND  FASCIA. 

By  James  F.  Mitchell,  M.D., 

Washington,  D.  C. 


We  are  accustomed  to  see  the  subject  of  tuberculosis  of  the  skeletal 
muscles,  tendons,  and  fascia  dismissed  with  a  few  words,  usually  amounting 
to  the  statement  that  it  does  occur  and  is  usually  secondary  to  a  tuberculous 
focus  elsewhere.  Careful  search  of  the  literature  brings  out  the  fact  that 
primary  tuberculosis  of  tendons  is  common,  and  that  primary  tuberculosis  of 
muscles  and  fascia  has  been  frequently  described.  The  French  seem  to  have 
been  especially  interested  in  tuberculosis  of  muscle  whereas  in  Germany 
the  tendons  and  fascia  have  received  more  attention. 

Tuberculosis  of  Muscle. — Secondary  tuberculosis  of  muscle  by  ex- 
tension is  very  common.  It  is  usually  seen  as  a  psoas  abscess  from  a  vertebral 
focus,  as  a  pectoral  abscess  having  its  origin  in  a  diseased  rib,  or  it  may  occur 
as  a  direct  extension  in  the  neighborhood  of  involved  bones  or  joints  elsewhere. 
Primary  tuberculosis  of  muscle  is  a  much  less  common  affair.  It  appears  to 
have  been  first  described  by  Habermaas  and  i\Iueller  *  in  1886.  Since  then 
the  number  of  true  cases  reported  is  small.  In  a  review  by  Kaiser,^  in 
1905,  only  eighteen  are  reported,  and  since  this  paper  I  can  find  reports  of  only 
three  others.  An  attempt  is  made  by  several  writers  to  explain  the  rarity 
of  this  disease.  Plantard,^  in  an  extensive  monograph  in  1901,  refers  to  the 
work  of  Richet,  explaining  its  infrequent  occurrence  in  cattle  as  due  to  a 
definite  germicidal  action  of  rnuscle.  Richet  supposes  in  the  muscle  a  tuber- 
culous antitoxin,  and  emphasizes  the  fact  that  no  one  has  ever  observed  a 
giant-cell  within  a  muscle-fiber. 

The  disease  is  apparently  almost  symptomless,  appearing  usually  in  young 
persons  as  one  or  several  nodules  in  the  course  of  a  skeletal  muscle.  Those 
muscles  most  exposed  to  traumatism  are  usually  attacked.  The  early  stage 
is  rarely  seen,  and  only  noticed  by  accident.  The  nodules  appear  as  masses 
in  the  substance  of  the  muscle,  usually  oval,  varying  in  size  and  elevating 
the  overlying  skin,  which  is  not  attached.  They  are  more  often  multiple, 
and  in  consistence  are  hard,  with  a  vague  sensation  of  fluctuation.  The 
tumor  appears  hard  when  the  muscle  is  contracted,  and  softer  when  it  is 
in  relaxation.  If  the  nodule  has  gone  on  to  caseation  and  abscess  formation, 
the  appearance  is  that  of  a  definite  cold  abscess.    There  is  usually  little  pain 

279 


280  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

and  no  fever,  the  diagnosis  being  based  most  often  on  preexisting  evidence 
of  tuberculosis,  or  tlie  appearance  of  such  masses  in  weak  and  tuberculous 
looking  individuals. 

Pathologically,  the  disease  presents  three  types:  the  tuberculous  nodule 
or  gumma,  the  cold  abscess,  and  the  tuberculous  muscular  cirrhosis.  These 
represent  merely  three  stages  of  the  same  affection,  the  nodule  being  the  early 
stage,  the  abscess  a  degenerating  stage,  and  the  cirrhosis  a  heahng  process. 
The  infection  is  probably  always  a  hematogenous  one,  and  the  establishment 
of  a  focus  is  due  to  the  lodgment  of  tubercle  bacilli  in  a  small  vessel  having 
its  final  distribution  in  a  muscle.  The  origin  and  extension  of  the  process 
are  in  the  connective  tissue,  and  the  statement  is,  therefore,  made  that  there 
is  no  true  tuberculosis  of  muscle,  but  rather  a  tuberculosis  of  the  muscular 
connective  tissue.  ]\Iicroscopically,  a  node  presents  three  areas:  an  outer 
zone  of  practically  normal  muscle;  a  middle,  in  which  the  muscle-fibers  are 
broken  up  and  separated  by  connective  tissue  rich  in  cells,  and  a  central  zone 
where  the  muscle-fibers  disappear  and  are  replaced  by  tuberculous  granu- 
lation tissue  or  caseous  material.  The  muscle-fibers  of  the  outer  zone  show 
their  normal  structure.  As  the  granulation  layer  is  approached  the  muscle- 
fibers  show  more  and  more  alteration.  Their  thickness  varies,  some  being 
larger  than  normal,  others  smaller,  and  in  places  the  striations  disappear. 
The  hypertrophied  connective  tissue  pushes  in  and  separates  the  individual 
fibers.  There  is  active  proliferation  of  the  nuclei  of  the  sarcoplasm,  which 
are  arranged  more  or  less  in  rows.  In  the  granulation  tissue  numerous 
typical  giant-cells  are  seen.  It  is  still  disputed  whether  or  not  these 
originate  in  part  from  the  sarcoplasm.  The  central  caseous  mass 
shows  fragmented  nuclei  and  particles  of  degenerated  muscle-fibers.  Tuber- 
cles and  giant-cells  are  seen  partly  in  the  large  fibrous  septa  and  partly  in  the 
finer  connective  tissue  separating  the  muscle-bundles  and  individual  fibers. 
The  actual  muscle  changes  then  consist  in  a  degenerative  atrophy,  the 
principal  reaction  being  in  the  connective  tissue.  The  coimective  tissue 
changes  gradually  lead  to  the  formation  of  a  thick,  hard  shell  around  the 
node,  which  may  result  in  a  spontaneous  cure;  or  if  the  reaction  is  not  so 
great,  to  the  formation  of  an  abscess.  The  appended  table  from  Kaiser 
gives  in  detail  the  location  of  the  disease  in  reported  cases,  with  the  treatment 
and  its  result.  To  this  list  may  be  added  three  reported  in  1907  by  Kirmisson^ 
and  Cornie,^  bringing  the  number  of  reported  cases  up  to  twenty-one.  In 
the  available  hospital  records  I  can  find  no  case  entered  as  primary  tuber- 
culosis of  muscle. 

Tuberculosis  of  Fascia. — The  ordinary  form  of  tuberculosis  observed 
in  the  fascia  is  the  extension  abscess  from  a  bone  focus.  Primary  tuber- 
culosis does  occasionally  occur,  and  as  such  has  formed  an  interesting  chapter 
in  the  study  of  cystic  tumors.    In  Progressive  Medicine  for  December,  1905, 


TUBERCULOSIS   OF   MUSCLES,   TENDONS,    AND    FASCIA. — MITCHELL.       281 


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SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 


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Bloodgood®  reviewed  the  literature 
of  lymph  cysts  of   the  thigh  and 
was  able  to  collect  a  few  cases.    In 
this  connection  the  following  inter- 
esting case  of  my  own  is  an  illus- 
tration.    In  March,  1903,  I  saw  a 
German  woman  of  fifty-four,  com- 
plaining of  a  tumor  of  the  left  thigh 
which  had  been  noticed  a  year  be- 
fore, and   had  been  gradually  in- 
creasing in  size  with   no  pain  or 
temperature  and  but  little  discom- 
fort.    The  woman  had  been  com- 
plaining for  some  time  of  "rheuma- 
tism," which  consisted  of  indefinite 
pains  in  the  back  and  limbs.   There 
was  no  family  history  of  tubercu- 
losis.    Examination  showed  a  very 
fat,    apparently    healthy    woman. 
Heart,  lungs,  kidneys,  and  general 
condition    were    normal.     On    the 
anterior  and  inner  surface  of  the 
left  thigh  was  a  large  tumor  ex- 
tending from  the  groin  nearly  to 
the  knee  in  the  region  of  the  ab- 
ductor  muscles.     The  tumor  was 
definitely  fluctuating,  the  skin  over 
it  was  normal;   there  was  no  ten- 
derness.    The  tumor  did  not  vary 
in  size,  but  was  more   tense  with 
the  knee  flexed.     There  was  no  im- 
pairment of  motion  of  the  leg.     No 
diagnosis  was  made  excej^t  that  of 
the  cj'stic  tumor,  and  its  removal 
was  advised.     The  operation  v/as 
done  under  cocain.    A  long  incision 
was  made  from  the  groin  nearly  to 
the  knee  on  the  inner  surface  of 
the  thigh,  and  the  cyst  was  excised 
by    an    extensive    dissection.      Its 
walls  were  in  intimate  connection 
with  the  fascia  between  the  abduc- 


TUBERCULOSIS   OF   MUSCLES,   TENDONS,    AND    FASCIA. — MITCHELL.       283 

tor  and  extensor  muscles  of  the  thigh,  so  that  when  the  tumor  was  re- 
moved, a  ragged  muscle  surface  was  left  in  many  places,  due  to  the  removal 
of  the  fascial  vralls  of  the  cyst.  The  cyst  extended  up  to  the  saphenous 
opening,  where  it  appeared  to  end.  Its  contents  consisted  of  clear  serum 
with  white  flakes  and  lumps  of  fibrin.  The  cyst  was  sent  to  Dr.  Blood- 
good  for  examination,  and  the  report  returned  that  its  walls  showed  tuber- 
culosis. The  specimen  and  the  original  report  have,  unfortunately,  been 
lost  in  the  laboratory.  The  wound  was  closed  and  healed  per  prirnam. 
Four  months  later  the  patient  developed  a  definite  tuberculosis  of  the  right 
ankle,  with  the  formation  of  an  abscess  resulting  in  sinuses  which  eventually 
healed.  There  has  been  no  evidence  of  tuberculous  disease  of  the  vertebrae 
or  pelvis.  Examination  in  July,  1908,  shows  the  patient  perfectly  well, 
there  ha^ang  been  no  recurrence  of  trouble  in  either  thigh  or  ankle. 

In  Bloodgood's  report  there  are  cited  three  similar  cases,  reported  by 
Narath,^  Strehl,^  and  Nordmann.^ 

Narath's  case  v>^as  that  of  a  girl  of  twenty-two  with  a  cystic  tumor  in 
apparently  the  same  situation  as  the  above,  but  varying  in  size  and  enlarging 
on  straining  or  coughing.  At  operation  it  was  found  to  extend  beneath 
Poupart's  ligament,  and  to  communicate  with  a  second  cyst  in  the  retro- 
peritoneal region.  A  very  extensive  operation  was  done  through  three 
incisions,  drainage  being  established  in  the  lumbar  region  and  below  Poupart's 
ligament.  The  patient  recovered  with  persistent  sinuses.  The  contents  were 
opaque  and  blood-tinged,  with  fibrinous  flakes.  The  walls  of  the  cyst  are 
described  as  being  fibrous,  with  an  endothelial  lining  on  the  surface  of  which 
necrotic  nodules  projected.  At  the  bases  of  these  nodules  there  were  giant- 
cells. 

Strehl's  case  occurred  after  the  publication  of  Narath's.  It  was  quite 
similar,  but  such  an  extensive  operation  was  not  done.  It  occurred  in  a  man 
of  twenty  who  had,  in  the  preceding  year,  suffered  with  traumatic  arthritis 
of  the  right  knee.  The  tumor  appeared  in  Scarpa's  triangle,  on  the  same 
side  between  the  adductor  and  extensor  muscles.  It  was  the  size  of  the  fist, 
with  a  definite  pedicle  extending  beneath  Poupart's  ligament.  It  was  com- 
pressible, and  changed  definitely  in  size  in  the  erect  or  rechning  position, 
becoming  larger  also  when  the  pressure  was  made  in  the  ihac  fossa.  There 
was  no  evidence  of  tuberculosis  of  vertebra3  or  pelvis.  The  operation,  con- 
sisting of  incision  and  the  injection  of  iodoform  and  glycerin,  resulted  in  the 
establishment  of  a  permanent  fistula.  The  patient  died  a  few  years  later 
of  what  was  evidently  tuberculosis.  Microscopical  examination  of  the 
cyst-walls  showed  typical  tuberculous  granulation  tissue.  Its  contents  were 
yellow,  serous  fluid  with  floating  flakes  of  fibrin, 

Nordmann's  case  was  a  true  lymph  cyst,  not  tubercular,  and  Baer's 
case,  reported  by  Bloodgood,  proved  to  be  a  sarcoma.     Dr,  Bloodgood,  in 


284  SIXTH   INTEENATIONAL   CONGRESS    ON  TUBERCULOSIS. 

a  personal  communication,  states  that  since  1905  he  has  encountered  three 
further  cases.  One  of  these  represents  the  common  history  of  apparently 
isolated  tuberculosis  of  fascia,  a  cystic  tumor  in  the  thigh  having  resulted 
from  the  extension  of  a  tuberculous  process  along  the  fascial  planes  from  an 
involved  knee.  The  knee  was  resected  and  cured,  and  at  the  time  of  tliis 
operation  an  extension  was  found  into  the  soft  parts.  Some  months  later 
the  patient  returned  with  a  cyst  in  the  middle  third  of  the  surface  of  the 
thigh,  which  proved  to  be  tubercular  and  contained  serous  fluid  with  floating 
flakes.  This  cyst  had  undoubtedly  formed  from  an  area  of  tuberculosis 
which  had  become  shut  off  from  the  original  point  by  healthy  scar  tissue. 

Recently  another  case  has  been  reported  by  Minssen  and  Weydemann,  ^° 
occurring  in  an  apparently  healthy  woman  of  twenty-five.  There  were 
two  more  or  less  symmetrical  cysts  of  the  thighs,  each  one  connecting  beneath 
Poupart's  ligament  with  a  retroperitoneal  extension.  There  was  no  con- 
nection between  the  cysts  on  the  right  and  left  side,  and  no  evidence  of  a 
bone  focus  of  tuberculosis.  These  cysts  likewise  proved  tubercular,  and  like 
the  previous  cases,  contained  clear  serum  with  fibrinous  flakes.  The  walls 
presented  the  appearance  of  tubercular  granulation  tissue.  Minssen  and 
Weydemann  considered  them  gravitation  abscesses. 

These  cysts  may  originate  in  a  congenital  or  an  acquired  closure  of  a 
pouch  of  peritoneum  present  in  the  situation  of  a  femoral  hernia,  or  they  may 
be  due  to  the  sac  of  a  gravitation  abscess  from  tuberculosis  of  bone  in  the 
pelvis  or  vertebrse.  The  bone  lesion  heals,  the  tuberculous  pus  disappears, 
and  is  replaced  by  a  clear  or  cloudy  fluid.  In  other  cases  the  cyst  has  no 
relation  to  the  tissues  above  Poupart's  ligament,  but  may  be  due  to  changes 
in  the  fascia  of  the  thigh  itself.  The  injury  of  a  lymphatic  vessel  may  lead 
to  rapid  extravasation  of  lymph,  which  becomes  encysted.  The  cysts 
may  occur  almost  anywhere  in  the  thigh,  but  are  apparently  most  common 
anteriorly,  between  the  abductor  and  the  extensor  muscles.  They  appear 
suddenly,  grow  rapidly,  and  cannot  be  differentiated  from  various  other 
tumors  until  explored  by  puncture  or  incision.  Koenig  emphasized  the  fact 
that  tuberculous  pus  from  a  bone  focus  follows  the  fascial  planes  and  forms 
for  itself  a  distinct  tuberculous  connective-tissue  wall  which  may  be  easily 
separated  from  the  surrounding  tissue.  When  the  tuberculous  process  be- 
comes inactive,  the  secretion  from  the  wall  is  less.  The  typical  tuberculous 
contents  change,  becoming  more  and  more  serous,  and  the  caseous  material 
gradually  disappears.  Eventually,  clear  serum  may  result.  Strehl  thinks 
these  cysts  are  tuberculous  gravitation  abscesses,  in  which  the  contents  have 
undergone  the  change  described  by  Koenig — an  opinion  in  which  Minssen  and 
Weydemann  concur.  In  my  own  case  the  termination  of  the  cyst  at  the 
saphenous  opening  might  suggest  the  same  explanation.  However,  as  no 
bone  focus  was  ever  discovered  about  the  cyst,  and  as  the  wound  healed 


TUBEECULOSIS    OF   MUSCLES,   TENDONS,    AND    FASCIA. — MITCHELL.       285 

without  the  formation  of  a  fistula,  it  would  seem  more  likely  than  in  other 
reported  cases  to  have  been  a  primary  fascial  tuberculosis. 

These  cystic  tumors  of  the  thigh  represent  the  most  interesting  side 
of  fascial  tuberculosis,  and  present  the  most  characteristic  picture  of  the 
affection.  The  condition  exists  in  other  regions,  especially  in  the  neck  and 
about  joints,  where  it  is  usually  plainly  secondary  to  a  tuberculous  focus  in 
gland  or  bone. 

Tuberculosis  of  Tendons. — Tuberculosis  of  tendon-sheaths  presents 
a  much  larger  literature  than  that  of  either  muscle  or  fascia,  and  is  a  much 
more  common  affection.  It  may  be  secondary  to  tuberculosis  of  bones  or 
joints,  arising  by  direct  extension  from  these  centers;  but  primaiy  involve- 
ment of  the  sheaths  of  tendons  with  no  other  evidence  of  tuberculosis  is  by 
no.  means  uncommon.  The  first  accurate  description  of  it  appeared  in  1779, 
by  Olav  Acrel,"  who  described  accurately  the  pecuhar  rice-bodies  from  which 
the  condition  has  derived  its  name  of  "ganglion  crepitans  Acrelid."  It 
is  also  known  under  the  name  of  "compound  ganglion,"  and  the  rice-bodies 
or  corpora  oryzoidea,  or  melon-seed  bodies  of  the  English,  have  received 
a  great  deal  of  attention.  Like  tuberculosis  of  muscle  and  of  fascia,  it  is  a 
more  or  less  sluggish  affection,  arising  quietly  with  little  pain  and  no  tem- 
perature, extending  gradually,  and  giving  few  symptoms  and  often  little 
loss  of  function.  It  runs  a  chronic  course,  and  is  not  hkely  to  lead  to  tuber- 
culosis in  other  regions.  Anatomically,  it  presents  two  types :  the  fungous 
variety,  analogous  to  the  joint  type  of  tuberculosis;  and  hygroma,  character- 
ized by  effusion  of  fluid  into  the  tendon-sheaths  and  by  the  presence  of 
rice-bodies.  Infection  is  through  the  blood-stream.  It  appears  most  often  in 
young  persons,  by  preference  in  those  with  a  preexisting  center  of  tuberculosis. 
Trauma  plays  an  important  role  in  its  history  by  causing  a  disturbance  in 
nutrition  and  extravasation  of  blood,  thus  preparing  a  locus  minoris  resis- 
tentice  for  the  reception  of  tubercle  bacilli  circulating  in  the  blood.  The  in- 
fluence of  trauma  is  evident  from  the  facts  that  it  appears  during  the  most 
active  period  of  life,  when  the  parts  are  most  subject  to  violence,  and  individ- 
uals attacked  are  those  in  whose  pursuits  trauma  is  most  likely,  those  persons 
engaged  in  heavy  manual  labor  being  more  disposed.  Its  localization  like- 
wise is  an  evidence  of  this  influence,  the  upper  extremity  being  its  most 
frequent  situation,  and  the  right  hand  more  common  than  the  left.  The 
palmar  tendons  are  more  frequently  involved  than  the  extensors.  It  is 
often  multiple,  frequently  symmetrical,  A  single  tendon  or  a  whole  group 
may  be  the  seat  of  the  disease.  It  appears  usually  as  a  swelling  in  the  region 
of  one  or  more  tendons,  which  increases  gradually  without  involvement 
of  the  skin,  in  the  fungous  variety  appearing  as  a  diffuse  homogeneous  thick- 
ening, with  more  or  less  tenderness,  in  the  hygroma  presenting  a  fluctuating 
tumor  in  which  there  may  be  a  definite  crepitation,  due  to  the  presence  of 


286  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

rice-bodies.  It  bears  a  close  resemblance  to  the  simple  or  non-tubercular 
"ganglion,"  wliicli  has  been  shown  to  be  an  actual  cystic  degeneration  of  the 
tendon-sheath.  Anatomically,  the  fungous  variety  is  represented  by  a  mass 
of  edematous  grayish  translucent  material,  which  more  or  less  entirely  fills 
the  tendon-sheaths.  This  tissue  is  usually  found  arising  from  the  parietal 
layer  of  the  sheath,  and  the  central  tendon  appears  normal.  On  the  other 
hand,  the  layer  covering  the  tendon  may  be  involved,  and  the  tendon  itself 
may  be  definitely  invaded.  This  type  may  go  on  to  caseation  and  abscess 
formation,  with  later  involvement  of  the  skin  and  the  formation  of  an  ulcer 
leading  to  spontaneous  cure,  with  resulting  contracture  and  loss  of  function, 
or  it  may  be  converted  into  hygroma  by  the  extravasation  of  fluid  and 
formation  of  rice-bodies. 

In  hygroma  the  tendon-sheaths  are  found  distended  with  clear  or  cloudy 
fluid,  in  which  float  fibrinous  flakes  and  the  so-called  rice-bodies.  The 
latter  may  be  few  in  Tiumber  or  may  completely  fill  the  distended  tendon- 
sheaths,  the  fluid  disappearing  and  the  sheath  being  packed  with  the  rice- 
bodies.  The  rice-bodies  may  eventually  disappear,  and  the  hygroma  be 
converted  into  the  fungous  type.  Actual  rupture  may  take  place,  in  which 
case  secondary  infection  is  jDrobable.  Hygroma  and  fungus  are  stages  of 
the  same  process,  and  between  them  are  many  gradations.  The  wall  of  the 
sheath  in  hygroma  varies  in  thickness;  its  surface  is  not  smooth,  but  is 
covered  with  numerous  excrescences.  Some  of  these  are  pedunculated, 
hanging  free  in  the  serum.  The  surface  of  the  tendon  and  of  the  sheath  is 
glistening,  and  apparently  covered  with  a  layer  of  fibrin. 

Microscopically,  the  sheath  in  fungus  consists  of  highly  vascular  connective 
tissue  with  extensive  cell  infiltration.  The  tissue  has  an  edematous  ap- 
pearance, and  the  general  structure  is  that  of  tuberculous  granulation  tissue 
in  other  regions.  In  hygroma  the  layers  of  the  tendon-sheath  are  found 
pushed  apart  by  the  infiltration  of  round-cells  and  leukocytes.  Scattered 
throughout  it  are  typical  tubercles,  and  the  tissue  as  a  whole  presents  the 
picture  of  tuberculous  granulation  tissue.  The  nearer  the  internal  surface 
of  the  sheath  is  approached,  the  more  the  tissue  assumes  a  degenerative 
fibrinoid  appearance,  staining  feebly,  and  showing  few  cells  or  nuclei.  The 
projecting  nodules  show  the  same  structure  as  the  rice-bodies  which  are 
floating  free.  On  the  surface  of  the  thickened  tendon  itself  there  appear  to  be 
layers  of  fibrin  and  tuberculous  granulation  tissue. 

The  rice-bodies  have  furnished  a  field  for  considerable  investigation  and 
controversy.  In  the  early  descriptions  they  were  thought  to  be  parasitic. 
They  were  then  considered  unorganized  concretions  on  which  fibrin  had  been 
deposited.  Hyrtl,  in  1842,  described  them  as  processes  from  the  wall  of  the 
tendon-sheath.  Koenig  adheres  to  the  coagulation  theory,  and  considers 
them  merely  products  of  fibrin  formation  from  the  extravasated  fluid. 


TUBERCULOSIS   OF   MUSCLES,    TENDONS,    AND    FASCIA. — MITCHELL.       287 

These  two  theories  represent  the  two  views  as  to  their  formation.  The 
question  is  not  yet  settled,  and  it  is  more  than  hkely  that  the  bodies  originate 
in  both  ways.  They  are  not  pathognomic  of  tuberculosis,  but  are  occasion- 
ally seen  in  non-tubercular  inflammations  of  the  tendon-sheaths. 

Histologically,  they  consist  of  stratified,  structureless,  fibrinoid  tissue, 
wdth  few  nuclei  and  occasional  giant-cells  or  tubercle  bacilli.  Inoculation 
of  animals  with  rice-bodies  has  given  positive  results  in  the  transmission  of 
tuberculosis.  The  generally  accepted  view  is  that  they  are  analogous  to 
the  foreign  bodies  of  joints,  that  they  are  formed  as  outgi'owths  from  the 
tendon-sheath,  which  gi-adually  become  pedunculated  and  are  finally  broken 
off  and  set  free.  In  support  of  this  is  the  fact  that  they  occur  most  often 
where  there  is  the  most  motion,  just  as  foreign  bodies  in  joints  are  found  to 
occur  only  in  those  joints  where  there  is  active  motion. 

The  treatment  of  tuberculosis  of  muscles,  tendons,  and  fascia  is  very 
satisfactory,  and  the  outlook  favorable.  i\Iany  cases  recover  spontaneously, 
and  in  general  they  may  be  included  under  the  milder  forms  of  tuberculosis. 
Tuberculosis  of  muscle  existing  in  the  form  of  nodules,  or  as  a  simple  cirrhotic 
myositis,  is  best  treated  by  complete  excision  and  suture.  Where  an  actual 
cold  abscess  has  formed,  excision  is  the  best  treatment  so  long  as  the'  area 
is  not  too  extensive.  In  extensive  abscesses  incision  and  evacuation,  with 
or  without  injections  and  closure,  have  given  good  results.  In  tuberculosis  of 
fascia  likewise  complete  excision  is  the  most  satisfactoiy  treatment,  and 
where  too  extensive  for  this,  incision  and  drainage  may  be  practised.  In 
tuberculosis  of  tendon-sheaths  entire  removal  of  the  affected  tissue  usually 
leads  to  permanent  cure.  In  all  three  affections,  as  in  all  varieties  of  surgical 
tuberculosis,  too  much  stress  cannot  be  laid  upon  the  importance  of  the  open- 
air  treatment,  as  has  been  so  well  demonstrated  by  Halsted.*^  The  method 
of  Bier  likewise  opens  up  a  brilliant  field,  and  may  be  combined  with  tuberculin 
injections.  Numerous  cases  are  recorded  in  which  excellent  results  have 
been  obtained  by  the  application  of  Bier's  hyperemic  method,  with  or 
without  operative  interference* 

REFERENCES. 

1.  Habermaas  and  Mueller:  Ref.  by  Plantard  and  others. 

2.  Kaiser:  Archiv.  f.  klin.  Chir.,  vol.  Ixxvii,  1905,  p.  1033. 

3.  Plantard:  Paris  thesis,  1901. 

4.  Kirmisson:  Bull,  de  I'acad.  de  med.,  1907,  No.  6. 

5.  Cornie:  Bull,  de  I'acad.  de  med.,  1907,  No.  8. 

6.  Bloodgood:  Progressive  Medicine,  December,  1905,  p.  249. 

7.  Narath:  Archiv.  f.  klin.  Chir.,  vol.  1,  p.  763. 

8.  Strehl:  Zeitschr.  f.  Chir.,  vol.  li,  p.  176. 

9.  Nordmann:  Deut.  Zeitschr.  f.  Chir.,  vol.  Ix,  p.  572. 

10.  Minssen  and  Weydemann:  Deut.  Zeitschr.  f.  Chir.,  vol.  Ixxxiii,  p.  577. 

11.  Acrel:  Quoted  by  Garr6.     Beit.  z.  klin.  Chir.,  vol.  xvii,  p.  203. 

12.  Halsted:  Trans.  Nat.  Assoc.  Study  and  Prevent.  Tuberculosis,  N.  Y.,  1906, 
pp.  281-303. 


288  SIXTH   INTERNATIONAL   CONGRESS  ON  TUBERCULOSIS. 

Tuberculose  des  Muscles,  Tendons  et  Fascies. — (Mitchell.) 
Tuberculose  des  muscles,  primaire  et  secondaire.  Tuberculose  pri- 
maire,  une  affection  rare.  Description  de  cas.  Re\aie  de  la  litterature. 
Types  de  la  maladie;  pathologie.  Tuberculose  de  I'aponevrose,  commune 
comme  maladie  secondaire;  rare  comme  affection  primaire.  Description 
des  cas.  Discussion  sur  les  cystes  lymphatiques  de  la  cuisse.  Tuberculose 
des  tendons, — la  forme  commune.  Types  de  la  maladie — le  fungus  et 
rhygrome.  Discussion  sur  la  formation  des  corps  oryzoides.  Traitement. 
Les  trois  types  de  la  maladie  dans  les  formes  plus  l^g^res  de  la  tuberculose 
g^n^rale.  Traitement  par  excision  ou  incision  suivie  d'injections.  Im- 
portance du  traitement  dans  I'air  libre  et  de  I'hyperemie  de  Bier. 


Tuberkulosis  der  Muskeln,  Sehnen,  und  Fascien. — (Mitchell.) 
Tuberkulose  der  Muskeln  ist  primar  und  secundar.  Primare  Tuberku- 
lose  eine  seltene  Krankheit.  Bericht  von  Fallen.  Ubersicht  der  Literatur. 
Typus  der  Krankheit;  Pathologie.  Tuberkulose  der  Fascien;  haufig 
durch  tjbergreifung;  selten  als  primare  Affektion.  Bericht  von  Fallen. 
Erortenmg  der  Lymphcysten  am  Oberschenkel.  Tuberkulose  der  Sehnen, 
die  haufige  Form.  Typen  der  Krankheit — Fungus  und  Hygrom.  Dis- 
kussion  der  Reiskorperchen-Bildung.  Behandlung.  Die  drei  Arten  der 
Krankheit  gehoren  zu  den  milderen  Formen  der  Tuberkulose.  Behandlung 
durch  Ausschneiden  oder  Einschneiden  und  Einspritzung. 


TUBERCULOSIS    OF    THE    STOMACH,    LIVER,    GALL- 
BLADDER, AND   PANCREAS. 

By  Lucius  W.  Hotchkiss,  M.D., 

Associate  in  Clinical  Surgery,  Columbia  University,    New  York  City. 


Until  very  recent  years  the  study  of  tuberculosis  of  the  abdominal  vis- 
cera has  remained  almost  entirely  within  the  domain  of  the  pathologist. 
During  the  last  twenty  years,  however,  and  more  especially  within  the  last 
decade,  the  surgeon's  knife  has  brought  under  inspection,  during  life, 
various  lesions  hitherto  undescribed,  and  has  caused  the  symptomatology 
pathology,  diagnosis,  and  treatment  of  abdominal  tuberculosis  to  be  placed 
upon  the  basis  of  observed  facts  and  conditions. 

In  the  case  of  tuberculosis  of  the  gall-bladder  and  of  the  pancreas  there 
is  but  little  of  surgical  interest  and  importance,  and  until  a  symptomatology 
can  be  established  which  may  serve  as  a  rational  basis  for  diagnosis  in  these 
exceedingly  rare  conditions,  they  will  remain,  as  at  present,  among  the  path- 
ological curiosities. 

In  the  case  of  the  stomach  and  liver,  however,  tuberculosis  may  occas- 
ionally assume  a  form  capable  of  being  diagnosticated,  and  one  in  which 
surgical  measures  may  be  more  or  less  effective. 

In  a  paper  of  this  sort  only  the  surgical  bearings  of  gastric,  hepatic,  and 
pancreatic  tuberculosis  will  be  considered  at  any  length,  as  an  elaborate  dis- 
cussion of  the  pathology  would  far  transcend  the  prescribed  limits. 

Tuberculosis  of  the  Stomach. 

This,  in  the  vast  majority  of  cases,  is  secondary  to  and  complicated  by  a 
preexisting  lung  tuberculosis,  and  not  infrequently  also  is  associated  with 
intestinal  tuberculosis  more  or  less  extensive. 

In  1886  Joseph  Coats  first  discovered  the  tubercle  bacillus  in  a  gastric 
ulcer.  Very  rarely  indeed  is  the  lesion  confined  to  the  stomach,  though 
Litten  has  reported  one  case  in  which  no  spot  of  ulceration  was  found  else- 
where in  the  digestive  tract,  and  Eppinger  also  has  made  a  similar  observa- 
tion. Lava  and  Orlandi  further  speak  of  the  failure  to  find  tubercular  lesions 
in  the  lungs  and  other  organs  in  one  case,  and  Leven  found  in  some  of  his 
cases  only  cheesy  mesenteric  glands  as  a  possible  focus  of  the  disease.  In 
VOL.  11—10  289 


290  SIXTH    INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

spite  of  these  and  other  observations,  it  is  beUeved  that  gastric  tuberculosis 
is  rarely  primary. 

Although  the  most  frequent  means  of  infection  in  gastric  tuberculosis 
was  thought  by  the  older  wi'iters  to  be  through  tubercle  bacilli  taken  with 
the  food,  or  through  tuberculous  sputum  which  had  been  swallowed,  it 
would  seem,  in  the  light  of  more  recent  investigation,  that  it  is  conveyed  very 
often  through  the  blood-stream  (Arloing),  and  through  the  extension  of  in- 
fection from  some  neighboring  tissue  or  organ  (Chiari,  Reinhold,  Beneke). 

The  normal  gastric  juice,  moreover,  while  it  has  no  specific  bactericidal 
qualities,  furnishes  a  certain  amount  of  protection  against  tubercle  bacilli 
in  infected  foods,  and  the  epithelium  of  the  gastric  mucosa  is  well  protected 
by  the  mucous  secretion,  which  tends  also  to  diminish  the  virulence  of  the 
germ. 

It  is  thought  that  the  perigastric  glands  are  often  the  primary  seat  of 
gastric  tuberculosis,  and  that  in  the  walls  of  the  stomach  the  lymphatics  of 
the  mucosa  are  probably  the  first  affected. 

Under  normal  conditions  of  the  stomach  there  is  a  great  resistance  to 
tubercular  infection.  In  inflammatory  conditions,  however,  as  a  result 
probably  of  alterations  in  the  normal  acidity  of  the  gastric  juice,  the  mucous 
membrane  may  become  more  vulnerable,  and  some  of  the  innumerable 
slight  abrasions  or  "micro  traumas"  which  are  received  in  the  region  of  the 
pylorus  may,  under  certain  conditions,  furnish  an  infectious  atrium.  It  is 
possible  also  for  retrograde  infection  from  the  duodenal  mucosa  to  occur 
(Durante,  Patella). 

Years  before  the  discovery  of  the  tubercle  bacillus  in  gastric  ulcer,  gas- 
tric tuberculosis  had  been  recognized  and  described  under  various  names,  as 
a  considerable  literature  attests.  That  it  is  a  rare  condition  all  the  autopsy 
records  show.  Thus  Eisenhardt,  out  of  1000  autopsies  in  tubercular  sub- 
jects examined  between  1886  and  1900  (in  the  Miinchener  Path.  Inst.) 
found  only  one  case  of  true  tubercular  ulcer  of  the  stomach. 

Kiihl  and  Glaubitt,  in  the  Kiel  Institute,  between  1873  and  1880,  found 
fourteen  cases.  Miliary  tuberculosis,  much  the  commoner  form  of  gastric 
tuberculosis,  does  not  for  the  present  concern  the  surgeon.  His  interest  is 
limited  to  the  ulcers  of  the  gastric  mucosa,  and  especially  to  the  pyloric 
stenoses  due  to  tuberculosis. 

Tubercular  ulcers  of  the  gastric  mucosa  are  very  rare.  Simmonds  saw 
but  eight  cases  of  secondary  chronic  tubercular  gastric  ulcer  in  the  course  of 
2000  autopsies  in  Hamburg  during  a  period  of  ten  years,  whereas,  during 
the  same  period  he  found  the  type  of  disease  which  forms  a  part  of  a  general 
miliary  tuberculosis  to  be  relatively  frequent. 

Ricard  and  Chevrier,  in  fifteen  years'  autopsy  experience  in  the  Paris 
hospitals,  observed  only  four  cases  of  tubercular  pyloric  stenosis.    The  tuber- 


STOMACH,    LIVER,    GALL-BLADDER,    PANCREAS. — HOTCHKISS.  291 

cular  gastric  ulcer  has  certain  features  which  serve  to  distinguish  it  from  the 
simple  round  ulcer  wliich  is  not  uncommonly  found  in  the  tuberculous. 
It  is  most  often  solitary,  but  occasionally  multiple.  In  size  it  is  generally 
small  and  in  shape  round,  though  it  may  reach  a  large  size,  as  in  the  classical 
case  of  Simmonds,  where  it  measured  20  by  10  cm. 

The  site  of  predilection  for  the  ulcer  is  the  pars  pylori.  Thus  out  of 
twenty-one  cases  collected  by  Letorey,  the  pylorus  was  affected  eight  times, 
the  greater  curvature  four  times,  the  anterior  and  posterior  wall  three  times, 
and  the  lesser  curvature  and  cardia  twice.  Struppler  found  one  ulcer  which 
extended  nearly  around  the  whole  pylorus,  and  which  led  to  perforation  and 
a  fatal  peritonitis. 

The  base  of  a  tubercular  gastric  ulcer  may  be  at  varying  depths.  It  may 
impinge  upon  the  muscularis  mucosae,  the  submocosa,  or  the  muscular  coat. 
Its  surface  is  yellowish  in  color,  or  a  pale,  grayish-red,  granulating  area, 
studded  over  with  tubercular  nodules.  The  microscope  shows  generally  an 
infiltration  of  the  submucous  coat  more  or  less  extensive,  and,  at  the  borders 
of  the  ulcer,  great  infiltration  of  round  cells  mixed  with  giant  cells  and  tuber- 
cular necrotic  foci  are  evident.  The  blood-vessels  are  often  the  seat  of  an 
endarteritis  or  endophlebitis,  as  in  sj^hilis,  and  tubercle  bacilli  are  to  be 
found  upon  the  surface  or  within  the  depths  of  the  ulcer. 

Sometimes  the  vessels  become  eroded,  as  in  simple  gastric  ulcer,  and  a 
fatal  hemorrhage  ensues.  Four  cases  reported  by  Arloing  met  with  such  a 
fate.  Sometimes  the  ulcer  may  extend  to  the  overlying  peritoneum  and  lead 
to  a  perforation  and  general  peritonitis,  or  adhesions  may  form  between  the 
stomach  and  neighboring  viscera  and  lead  to  fistulous  communication  with 
other  parts  of  the  alimentary  tract.  This  Letorey  reports  one  case  in  which 
the  base  of  a  tubercular  gastric  ulcer  was  formed  by  the  adherent  liver,  and 
Mathieu  and  Remond  observed  a  fistulous  communication  between  the  dis- 
eased pylorus  and  the  duodenum. 

Hilgenreiner,  out  of  the  older  literature,  found  two  cases  of  fistula  be- 
tween the  stomach  and  the  transverse  colon,  viz.,  Abercrombie's,  1843,  and 
Oppolzer's,  1867. 

A  combination  of  tuberculosis  and  carcinoma  of  the  stomach  occasionally 
occurs,  and  the  theory  of  such  a  coincidence  is  that  the  carcinoma  may  be 
engrafted  upon  the  tuberculosis,  as  a  result  of  the  decreased  resistance  fur- 
nished by  the  diminution  of  the  normal  gastric  acidity.  It  must  be  remem- 
bered that  the  simple  round  ulcer  of  the  stomach  not  infrequently  occurs  in 
the  course  of  pulmonary  phthisis,  and  one  writer  goes  so  far  as  to  state  his 
beUef  that  most  cases  giving  definite  symptoms  of  gastric  ulcer  under  these 
conditions  are  not  tubercular  ulcers. 

A  case  in  point  recently  came  under  my  own  charge,  in  1906,  and  was 
operated  upon  by  me. 


292  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

Case:  J.  C,  Italian,  aged  forty-one,  admitted  to  Roosevelt  Hospital, 
June,  1906,  suffering  from  pulmonary  tuberculosis,  and  for  the  last  six 
months  from  symptoms  of  gastric  ulcer.  Nausea,  epigastric  pain  after  eat- 
ing, marked  hyperacidity  of  the  stomach  contents,  with  some  epigastric 
tenderness  were  the  principal  features. 

The  case  had  been  referred  for  surgical  treatment  for  the  reason  that  the 
stomach  condition  rendered  ineffectual  all  efforts  toward  proper  feeding  for 
the  betterment  of  his  lung  tuberculosis. 

Operation,  June  18,  1906,  revealed  a  chronic  ulcer  with  indurated  edges, 
represented  by  a  hardened,  round,  adherent  area  upon  the  posterior  surface 
of  the  stomach,  about  midway  between  the  borders  and  about  3  inches  from 
the  pylorus.  There  was  no  pyloric  stenoses,  so  the  ulcer  was  excised  and  the 
wound  closed.  Prompt  recovery  ensued  and  the  general  treatment  of  his 
lung  condition  was  resumed  successfully.  The  patient  is  at  present  in  good 
health. 

Besides  the  lesions  of  the  stomach  which  are  obviously  tuberculous, 
Poncet  and  Leriche  have  recently  described  a  third  form  of  tubercular  dis- 
ease, to  wit,  a  hypertrophic  form,  analogous  to  the  hypertrophic  intestinal 
tuberculosis,  and  which  has  its  localization  especially  in  the  pylorus.  In 
this  form  it  is  impossible  to  state,  they  say,  exactly  to  what  extent  the 
tubercular  element  is  causal. 

Diagnosis. — The  diagnosis  of  tubercular  gastric  ulcer,  with  or  without 
pyloric  stenosis,  is  always  very  difficult,  and  often  quite  impossible.  Those 
cases  in  which  the  ulcer  does  not  involve  the  pylorus  have  no  absolutely  dis- 
tinctive features,  and  are  practically,  as  far  as  present  knowledge  is  concerned 
entirely  without  the  domain  of  surgery.  All  cases  observed  in  the  course  of 
operation  or  autopsy  should  be  carefully  studied,  therefore,  with  reference 
to  any  points  in  their  symptomatology  which  may  perhaps  form  a  basis  for 
rational  diagnosis  and  treatment. 

Pain  in  the  region  of  the  stomach,  anorexia,  vomiting,  occasionally  of 
blood,  together  with  the  cough,  the  diarrhea,  and  the  cachexia  of  the  accom- 
panying pulmonary  lesion,  make  up  the  clinical  picture.  These  features, 
however,  are  not  sufficiently  distinctive  to  frame  even  a  probable  diagnosis, 
nor  does  the  gastric  analysis  help  one  to  more  definite  conclusions  in  these 
cases.  To  be  sure,  hyperchlorhydria  is  the  rule  in  simple  ulcer,  and  the 
reverse  in  the  tubercular  type;  still,  in  some  cases  the  rule  does  not  hold, 
and  the  tubercular  ulcer  of  the  stomach,  in  numerous  reported  cases,  has 
been  characterized  by  hypersecretion  and  hyperacidity,  so  that  we  are  not, 
with  the  data  at  our  disposal,  able  to  base  our  conclusions  upon  gastric 
analysis. 

One  important  feature  in  tubercular  gastric  cases  is  diarrhea,  and  this 
even  in  cases  where  there  is  no  intestinal  involvement.  But  diarrhea  is 
so  common  a  complaint  in  cases  of  pulmonary  tuberculosis  that  it  will  prob- 
ably not  attract  attention  in  most  cases  sufficiently  to  aid  in  making  the 


STOMACH,    LIVER,    GALL-BLADDER,    PANCREAS. — HOTCHKISS.  293 

diagnosis.  The  reliability  of  tuberculin  in  fixing  the  diagnosis  is  unfortunately 
doubtful,  and  its  use  is  not  free  from  danger.  It  seems  highly  probable, 
therefore,  unless  the  ulcer  be  situated  at  or  near  the  pylorus,  and  gives  rise 
to  very  definite  symptoms  of  stenosis,  that  the  diagnosis  will  not  be  made. 

When  stenosis  of  the  pylorus  occurs  in  a  case  of  tuberculosis  of  the  stom- 
ach, the  symptoms  are  the  same  as  in  stenosis  from  other  causes,  except  that 
perhaps  diarrhea  is  more  apt  to  be  present  in  the  tubercular  cases,  whereas 
constipation  is  the  general  rule.  Wide  dilatation  may  occur  when  the  stom- 
ach is  free  from  adhesions;  and  while  the  characteristic  gastric  peristaltic 
wave  is  not  demonstrable  in  all  cases,  this  is  probably  a  matter  of  adhesions 
rather  than  a  special  feature  of  the  tubercular  cases.  There  are  two  varie- 
ties of  tubercular  pyloric  stenosis — one  with  a  rapid  course,  and  the  other 
with  a  rather  slow  course.  The  former  variety  is  the  more  common.  Stenosis 
generally  develops  much  more  rapidly  in  the  tubercular  cases  than  in  the 
cases  of  carcinoma  of  the  pylorus,  and  intercurrent  disease  is  a  much  more 
frequent  accompaniment. 

Alessandri  gives  a  resume  of  the  Hterature  of  cases  of  tubercular  pyloric 
stenosis  in  wliich  the  diagnosis  was  made  in  the  course  of  an  exploratory 
laparotomy,  and  concludes  that  the  number  of  cases  would  be  somewhat 
greater  if  all  cases  of  stenosing  and  non-stenosing  new  formations  at  the 
P3'lorus  were  submitted  to  careful  microscopical  examination.  His  own  case 
was  a  girl,  aged  twenty-one,  who  had  been  sick  for  seven  months  with  symp- 
toms of  pyloric  stenosis,  with  great  enlargement  of  the  stomach,  and  a  pal- 
pable mass,  the  size  of  a  hen's  egg,  under  the  lower  right  ribs,  which  was 
movable.  The  pylorus  was  resected.  There  were  no  adhesions  and  the 
operation  was  easy.  Examination  of  the  excised  portion  showed  stenosis 
of  the  pylorus  by  a  tubercular  mass.     A  good  recovery  ensued. 

Ricard  and  Chevrier  report  four  cases  of  pyloric  tuberculosis.  In  review- 
ing the  subject  these  writers  found  that  primary  pyloric  tuberculosis  with 
stenosis  had  only  been  observed  three  times  in  one  hundred  and  seven  cases 
of  tuberculosis  of  the  stomach. 

Nordmann  reviews  one  hundred  and  twenty-six  cases  of  operated  gastric 
tumors,  among  which  only  one  was  a  case  of  tuberculosis.  In  this  case  a 
hypertrophic  tuberculosis  of  the  submucosa,  blocking  the  pylorus,  was 
present.  It  occurred  in  a  woman  thirty-seven  years  old,  in  whom  a  clinical 
diagnosis  of  carcinoma  had  been  made,  and  a  pylorectomy  performed. 
There  were  no  clinical  evidences  of  tuberculosis  either  at  the  time  of  opera- 
tion or  two  years  later,  after  healing.  In  this  case  hydrochloric  acid  was 
absent  and  lactic  acid  present  in  the  analysis  of  stomach  contents  before 
operation.    Nordmann  regards  this  as  a  case  of  probable  infection  per  orem. 

Jacobs  reported  a  case  in  a  girl  of  seventeen  upon  whom  he  performed  a 
laparotomy  for  tubercular  peritonitis  with  good  results,  but  in  whom  one 


294  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

year  later  symptoms  of  pj'loric  stenosis  developed,  for  which  he  performed 
gastro-enterostomy.  At  the  operation  he  found  the  pylorus  obstructed  by 
a  ring-like  mass  of  indurated  tissue  which  he  traced  back  to  a  proliferation 
from  the  original  trouble.     The  case  recovered. 

Of  thirteen  cases  of  tubercular  pyloric  stenosis  reported  by  another  writer, 
seven  were  between  twenty  and  thirty  years  of  age  and  six  were  scattered 
about  equally  between  the  other  periods  of  life.  This  corresponds  generally 
to  the  observations  of  others — that  tubercular  disease  of  the  stomach, 
whether  primary  or  secondary,  belongs  to  the  earlier  periods  of  life. 

Certain  cases  of  stenosis  at  the  p3dorus  have  been  observed  which  were 
due  to  pressure  of  masses  of  tuberculous  glands  in  the  neighborhood,  or  to 
adhesions  of  peripyloric  formation.  Such  cases  have  been  reported  by 
Ricard  and  Chevassu,  Godart  and  Leven. 

Prognosis. — ^The  prognosis  in  these  cases  depends  upon  the  condition  of 
the  other  organs  of  the  body.  Rarely  will  the  surgeon  meet  with  an  ideal 
case  for  resection,  yet  such  cases  have  been  reported. 

The  surgical  treatment  in  cases  of  stomach  tuberculosis  may  be  pallia- 
tive or  radical.  Under  palliative  measures  gastro-enterostomy  is  the  opera- 
tion of  choice,  since  pyloroplasty  and  gastrolysis  have  generally  been  found 
inapplicable  or  entirely  wanting  in  efficiency.  As  a  means  of  radical  extir- 
pation of  the  local  disease,  resection  may  be  considered,  i.  e.,  pylorectomy  or 
partial  gastrectomy. 

To  the  ten  cases  of  operation  for  tubercular  pyloric  stenosis  collected  by 
Ricard  and  Chevrier  in  1905,  Brenner  adds  eleven,  bringing  the  number  up 
to  twenty-one,  as  follows :  14  gastro-enterostomies,  4  resections,  5  pyloro- 
plastic,  1  gastrolysis.  Of  the  four  cases  of  resection,  the  diagnosis  was 
absolute  in  three;  in  the  fourth,  Alexander's  case,  it  is  most  probable.  All 
were  resected  under  the  impression  that  they  were  cases  of  carcinoma. 

Billroth's  method  No.  2  was  used  twice,  and  Kocher's  once;  in  the  fourth 
case  the  method  is  not  stated.  Two  cases  recovered,  two  died  as  a  result  of 
the  operation.  In  one  case  of  recovery  (Koerte's)  the  patient,  eighteen 
months  after  operation,  was  still  alive,  but  had  "apical  catarrh." 

Of  the  fourteen  gastro-enterostomies,  a  histological  diagnosis  was  made 
in  seven,  and  in  the  others  the  gross  appearances  were  sufficiently  conclusive. 
Twice  was  the  stenosis  extraparietal,  being  caused  by  compression  of  tuber- 
culous glands.     Clinical  evidences  of  high-grade  stenosis  were  present. 

In  one  case  the  gastro-enterostomy  was  secondary  to  a  pyloroplasty  wliich 
was  ineffective.  Seven  cases  were  operated  on  by  the  retrocolic  anastomo- 
sis and  two  cases  by  the  anterior  method.  In  five  cases  the  method  is  not 
described. 

One  of  the  anterior  gastro-enterostomies  developed  symptoms  of  "vicious 
circle"  and  called  for  a  later  entero-anastomosis.     And  in  one  case,  besides 


STOMACH,    LIVER,    GALL-BLADDER,    PANCREAS.— HOTCHKISS.  295 

the  gastro-enterostomy,  an  entero-plastic  operation  was  done  for  an  accom- 
panying intestinal  stenosis. 

One  case  was  well  after  three  years;  one  case  died  three  and  one-half 
years  after  operation,  of  multiple  tuberculosis.  One  case  died  after  a  year, 
of  tubercular  peritonitis;  one  after  eight  months,  from  the  same  cause;  one 
after  ten  months  of  multiple  tuberculosis.  Two  cases  died  of  lung  tubercu- 
losis after  one  month.  In  two  cases  operative  recovery  is  reported.  In  one 
case  no  details  are  given.  In  one  case,  after  two  months,  a  second  operation 
was  necessary.  In  most  cases  which  recovered  from  the  operation  the  result 
was  the  same  as  in  inoperable  carcinoma,  i.  e.,  palliative,  in  that  the  star- 
vation was  relieved  and  the  patient  made  more  comfortable. 

Both  cases  of  p5doroplasty  fared  badly;  the  one,  Ruge's  case,  developed 
symptoms  which  necessitated  a  later  gastro-enterostomy.  In  the  second 
case.  Mayo  Robson's,  which  did  well  for  a  week,  the  patient  suddenly  got 
worse  and  died  in  two  weeks.  The  operator  remarks  that  "with  my  present 
experience  I  should  have  performed  gastro-enterostomy  and  begun  feeding 
at  once,  and  I  believe  the  result  would  have  been  different."  The  case  of 
gastrolysis  of  Ricard  and  Chevrier  was  not  improved,  and  died  a  few  months 
later  of  perforation  and  hemorrhage. 

In  summing  up  these  results  Brenner  remarked :  "The  outlook  of  opera- 
tive treatment  in  these  cases  is  bad.  The  patients  are  tubercular,  remain 
tubercular,  and,  for  the  most  part,  in  a  short  time  die  tubercular.  Of  the 
twenty-one  cases  (one  operated  twice),  only  two  are  known  to  be  alive  after 
three  years,  and  two  which  lived  two  years.  Of  the  others,  most  of  them 
died  in  the  course  of  a  year,  and  a  good  part  of  them  shortly  after  operation. 
Perhaps,"  he  concludes,  "the  statistics  of  fifty  years,  with  larger  numbers 
reported,  will  show  a  more  pleasant  history."  He  looks  forward  to  a  time 
when  some  internal  specific  may  be  found  which  will  act  as  an  adjuvant  to 
the  necessary  surgical  measures.  Summing  up  the  operative  results  in  all  his 
collected  cases,  Brenner  agrees  .with  Ricard  and  Chevrier  that  pylorectomy  is 
dangerous  and  often  not  radical,  except  in  the  very  rare  case  of  movable 
pylorus  with  no  adhesions  or  other  involvement  of  the  glands  or  other 
organs;  that  gastrolysis  and  pyloroplasty  are  absolutely  ineffectual,  and 
that  gastro-enterostomy  under  the  usual  conditions  found  gives  the  best  re- 
sults, and  is  the  logical,  correct,  and  most  effective  measure  at  the  command 
of  the  surgeon. 

Tuberculosis  of  the  Liver. 

Tuberculosis  of  the  liver  is  probably  always  secondary  to  either  an  intes- 
tinal or  a  general  miliary  tuberculosis.  The  relatively  great  frequency  of 
intestinal  as  compared  with  stomach  tuberculosis  makes  tuberculosis  of  the 
liver  also  of  rather  more  frequent  occurrence;  and,  similarly,  the  age  at  which 
it  most  frequently  occurs  is  in  childhood.     Infection  is  generally  conveyed 


296  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

through  the  blood-stream,  though  the  bile-ducts  cannot  be  entirely  elimi- 
nated as  possible  channels,  in  view  of  the  experimental  work  of  Sergent 
(1895).  Involvement  through  the  lymphatic  current  probably  does  not 
occur.  The  tubercle  bacilli  may  be  conveyed  to  the  hver  through  the  portal 
vein  or  the  hepatic  artery.  When  thi'ough  the  latter  channel,  the  liver  tu- 
berculosis forms  merely  part  of  a  systemic  infection. 

Another  source,  however,  must  be  included  as  a  possibility,  i.  e.,  the  toxic 
influence  directly  or  indirectly  exercised  by  the  tubercle  bacilli.  Certain 
cirrhotic  changes  are  believed  to  be  due  to  this  cause,  and  even  when  tubercle 
bacilli  are  not  found,  these  cases  are  still  to  be  considered  as  of  tubercular 
origin. 

Although  tuberculosis  of  the  liver  is  generally  not  recognized  during  life, 
there  are  numerous  striking  instances  where  it  has  led  to  definite  symptoms. 
It  may  occur  in  the  form  of  miliary  tubercles  upon  the  surface,  or  scattered 
through  the  organ,  which  may  be  considerably  enlarged.  These  cases  are 
observed  in  the  course  of  a  general  miliary  tuberculosis,  form  a  part  of  a 
general  systematic  infection,  and  are  outside  the  field  of  surgery. 

The  second  form  of  liver  tuberculosis  is  represented  by  the  occurrence  of 
caseating  masses  of  various  size  and  variable  location.  This  is  a  more 
chronic  process  and  includes  occasional  cases  which  are  amenable  to  surgery. 
Rome  reports  having  successfully  excised  such  a  mass. 

The  third  form  of  liver  tuberculosis,  and  the  one  which  especially  inter- 
ests the  surgeon,  is  the  tubercular  abscess.  This  may  be  regarded  as  a 
later  phase  of  the  caseating  variety. 

The  first  stage  in  the  formation  of  these  tubercular  liver  abscesses  ap- 
pears to  be  the  formation  of  tubercular  foci  in  the  portal  spaces.  These  as 
they  increase,  often  by  conglomeration,  form  variable  sized  and  shaped 
masses,  which,  breaking  down,  may  occasionally  perforate  into  the  bile- 
ducts,  causing  a  cholangitis.  These  abscesses  may  remain  well  witliin  the 
substance  of  the  liver,  or  they  may  approach  the  surface  of  the  liver,  giving 
rise  to  a  palpable  tender  tumor.  Or  they  may  form  adhesions  between  the 
liver  and  the  diaphragm,  leading  to  the  formation  of  a  tubercular  subphrenic 
abscess  or  a  perihepatic  abscess  in  other  situations. 

Perihepatic  abscesses  are  believed  to  be  much  more  common  than  the 
intrahepatic  variety,  and  although  these  tubercular  affections  of  the  liver, 
in  occasional  cases,  may  be  the  only  local  manifestations  of  the  disease,  as 
a  rule  they  constitute  but  a  small  part  of  the  pathological  condition. 

Intrahepatic  abscesses  are,  as  a  rule,  of  small  size,  but  may  exceptionally 
attain  considerable  dimensions,  as  in  the  case  cited  by  Waring.  In  most  cases 
of  such  tubercular  liver  abscess,  no  special  symptoms  are  present  which 
depend  upon  its  existence,  and  it  is  frequently  only  discovered  at  autopsy. 

The  perihepatic  variety,  however,  which  is  the  more  common,  generally 


STOMACH,    LIVER,    GALL-BLADDER,    PANCREAS. — HOTCHKISS.  297 

begins  as  a  localized  tubercular  process  in  some  superficial  portion  of  the 
liver,  and  extends  toward  the  surface,  where  it  causes  a  perihepatitis  and  the 
formation  of  inflammatory  adhesions  between  the  covering  of  the  liver  and 
that  of  some  adjacent  organ.  These  adhesions  help  to  localize  the  abscess 
to  the  region  of  the  diseased  portion  of  the  liver,  and  to  prevent  the  occurrence 
of  a  general  peritoneal  tuberculosis. 

Any  part  of  the  liver  may,  of  course,  be  affected,  but  the  convexity  of 
the  right  lobe  is  the  part'which  has  been  most  commonly  involved.  In  the 
rare  cases  where  the  inferior  aspect  of  the  liver  is  the  seat  of  the  disease,  it 
may  happen  that  a  locahzed  chronic  abscess  is  found,  which  may  exist  for  a 
long  time  without  giving  symptoms  which  render  the  diagnosis  possible, 
and  sooner  or  later  such  an  abscess  spreads  toward  the  antero-inferior 
border  of  the  gland,  and  the  adjacent  portion  of  the  abdominal  walls,  and 
causes  a  swelling  which  is  palpable  and  which  exhibits  the  characteristics  of 
a  localized  abscess.  In  some  cases,  however,  the  inflammatory  process 
spreads  to  the  peritoneum  and  sets  up  a  tubercular  peritonitis,  which  may 
become  more  or  less  general,  and  which  is  accompanied  by  symptoms  which 
are  characteristic  of  this  disease. 

Diagnosis  in  cases  of  tuberculosis  of  the  liver  in  which  an  intrahepatic 
abscess  is  present,  is  practically  impossible,  since,  as  a  rule,  there  is  no  con- 
siderable enlargement  of  the  organ  and  there  is  no  special  train  of  symptoms. 
The  subplirenic  variety,  however,  gives  rise  to  certain  physical  signs  similar 
to  those  in  ordinary  subphrenic  abscesses,  such  as  are  due  to  the  extension  of 
a  tubercular  process  from  the  lung  or  pleura.  When  the  lower  surface  of 
the  liver  is  involved,  the  diagnosis  is  generally  not  possible  until  the  inflamma- 
tory process  has  extended  to  the  adjacent  portion  of  the  anterior  abdominal 
wall,  and  a  localized  abscess  has  been  formed. 

The  tubercular  nature  of  an  abscess  in  connection  with  the  liver  may 
sometimes  be  made  out  by  an  examination  of  the  fluid  withdrawn  at  an  ex- 
ploratory puncture.  Tubercle,  bacilli  may  be  found  in  the  material  so  with- 
drawn, but  this,  too,  is  by  no  means  the  rule,  since  in  a  very  old  tubercular 
lesion  it  is  not  possible  always  to  find  the  bacilli  at  the  first  examination. 
The  contents  of  these  abscesses  are  generally  very  thick,  and  it  may  be  nec- 
essary to  wash  out  the  needle  before  the  matter  can  be  drawn  and  examined. 
Treatment  in  these  cases  is  surgical,  as  in  other  cases  of  hepatic  abscess. 
In  order  to  promote  the  easy  evacuation  of  contents  in  the  central  abscesses 
it  is  recommended  to  scrape  the  walls  of  the  abscess  with  a  Volkmann's 
spoon  and  pack  the  cavity  with  iodoform  gauze. 

As  the  liver  abscess  is  generally  but  one  part  of  the  pathological  picture, 
appropriate  treatment  of  the  other  organs  should  be  carried  out  also.  When 
the  abscess  is  on  the  inferior  surface  of  the  Uver  and  appears  as  a  swelling 
of  the  anterior  abdominal  wall  beneath  the  situation  of  the  lower  edge  of  the 


298  SIXTH    INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

ribs,  an  incision  over  the  most  prominent  part  of  the  swelling  is  made,  and 
the  cavity  of  the  abscess  irrigated  and  drained. 

Incision  in  the  subphrenic  abscess  which  does  not  present  anteriorly  may 
be  made  through  the  thoracic  wall  by  resection  of  ribs  or  in  the  lumbar 
region  following  the  lower  border  of  the  last  rib.  The  location  and  connec- 
tion of  the  abscess,  of  course,  determine  the  method  of  approach. 

Prognosis. — In  most  cases  of  tubercular  abscess  of  the  liver  the  prog- 
nosis is  not  good,  on  account  of  the  associated  lesions  in  other  organs,  es- 
pecially the  lungs.  When,  however,  it  is  localized  to  the  liver,  and  it  is 
early  diagnosticated  and  promptly  evacuated,  it  is  possible  that  the  patient 
will  remain  well  if  other  conditions  can  be  dealt  with  by  general  measures. 

Tuberculosis  of  the  Gall-bladder. 

Most  of  the  standard  works  make  no  mention  of  tuberculosis  in  the  gall- 
bladder. It  is  an  exceedingly  rare  affection.  Maylard,  in  his  latest  work 
on  abdominal  tuberculosis,  makes  brief  reference  to  it,  and  quotes  a  case  of 
Lancereaux,  quoted  by  Rolleston,  in  which  the  common  bile-duct,  the 
cystic  duct,  and  the  gall-bladder  were  involved  in  a  tubercular  inflammation 
in  a  woman  of  thirty-two.  In  this  case  it  was  supposed  that  the  infection 
had  been  derived  by  direct  extension  from  the  duodenum. 

Holmes  quotes  Sergent  as  having  encountered  cases  of  gall-bladder  tu- 
berculosis, but  in  nearly  all  there  was  general  systemic  tuberculosis  present. 

Kirsch*  reports  a  case  in  a  woman  of  fifty-seven  in  which  the  wall  of  the 
gall-bladder  was  completely  destroyed  by  tuberculosis.  The  autopsy  showed 
the  gall-bladder  adherent  to  neighboring  organs,  especially  the  duodenum 
and  transverse  colon.  The  colon  communicated  directly  with  the  gall- 
bladder through  a  small  opening.  In  the  gall-bladder  were  numerous  stones 
and  thick  yellow  pus.  The  walls  of  the  organ  were  badly  infected  and  the 
inner  lining  was  covered  with  caseous  deposits.  Under  the  peritoneum  the 
wall  of  the  gall-bladder  was  replaced  by  caseous  masses  of  a  grayish  sub- 
stance. The  process  extended  also  to  the  liver  and  involved  the  cystic 
duct  to  its  distal  fourth.  The  microscope  confirmed  the  clinical  diagnosis. 
Tuberculosis  of  the  gall-bladder  is  practically  always  part  of  a  systemic 
infection. 

Tuberculosis  of  the  Pancreas. 

The  more  careful  examination  of  the  pancreas  at  autopsy  in  recent  years, 

in  the  course  of  investigations  of  its  various  diseases,  has  led  to  the  discovery 

that  it  is  rather  more  frequently  involved  in  tubercular  disease  than  a  study 

of  the  earlier  literature  would  lead  one  to  believe.     Still,  tuberculosis  of  the 

*  "  Ueber  einen  Fall  von  Cholecystitis  tuberculosa  chronica,"  Prag.  med.  Woch., 
No.  6,  1902. 


STOMACH,    LIVER,    GALL-BLADDER,    PANCREAS. — HOTCHKISS.  299 

pancreas  is  an  extremely  rare  affection,  is  most  frequent  in  children,  and 
practically  always  is  a  secondary  lesion. 

The  pancreas  may  be  infected  by  tuberculosis  through  the  blood,  or  by 
contiguity.  While  infection  through  the  duct  of  Wirsung  is  possible,  it  is 
regarded  as  very  improbable,  for  the  bacilli  would  have  to  enter  the  organ 
against  the  natural  current.  In  the  pancreas,  as  in  the  liver,  we  find  miliary 
tubercles,  or  caseous  masses,  and  these  masses  may  break  down  to  form 
abscesses.  In  a  case  reported  by  Mayo  Robson  an  abscess  was  found  which 
burrowed  behind  the  peritoneum  and  presented  in  the  loin  like  a  spinal 
abscess.  Oser  refers  to  abscesses  bursting  into  the  intestine,  and  Kudretslcy 
reports  a  similar  occurrence. 

The  cases  of  so-called  tubercular  abscesses  of  the  pancreas  are  found 
often  not  to  be  cases  of  real  pancreatic  tuberculosis,  but  rather  cases  of 
tubercular  masses  in  the  adjacent  lymph-nodes.  Most  cases,  indeed,  of 
large  caseating  masses  in  the  region  of  the  pancreas  on  closer  examination 
have  been  found  to  be  examples  of  lymphatic  gland  tuberculosis,  and  not 
tubercular  pancreas.  The  remarkable  case  of  Sendler  was  found  on  micro- 
scopical examination  to  be  really  a  tubercular  gland,  the  size  of  a  walnut, 
from  the  neighborhood  of  head  of  the  pancreas.  It  may  be  true,  after  all, 
that  the  pancreas  itself  is  rarely  the  seat  of  tuberculosis. 

Infection  from  the  overlying  peritoneum  or  from  the  kidney  may  take 
place.  Here,  as  in  the  liver,  a  peculiar  form  of  cirrhosis  may  also  occur  as 
a  result  of  the  toxic  influence  of  the  tubercular  infection,  and  without  the 
local  existence  of  the  tubercle  bacilli.  The  symptoms  in  the  few  recorded 
cases  are  of  no  diagnostic  value.  The  presence  of  a  tumor,  together  with 
other  facts  suggestive  of  tuberculosis,  may  lend  some  aid  in  the  differential 
diagnosis. 

BIBLIOGRAPHY    (Partial). 

Abeille:  "Un  cas  de  t.  b.  pancreatique,"  Marseilles  Med.,  1906,  p.  401. 

Alesandri,  R.:  "Tuberlc.  de  Pilorq.  Resection,"  and  Bull,  dell  R.  Acad,  di  Roma,  1895. 

Alexander,  M.:  "Beitrag  zur  Tuberc.  des  Magens,"  Deutsche  Archiv.  f.  kl.  Chir.,  1905- 

06,  No.  86. 
Arloing,  F. :  "Des  Ulcerations  tuberc.  de  re.stomac." 

Bandouin:  "La  cirrhose  tuberc.  chez  I'enfant,"  Rev.  Meus.  des  Mai.  de  I'infante,  1902. 
Barlow,  T.:  "On  a  case  of  t.  b.  of  Pane,"  Trans.  Path.  Soc.  London,  1875-76,  p.  173. 
Beneke:  Virchow,  Jahresbericht,  1851,  T.  iii. 
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des  Magens  und  Darmtract." 
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Carnot,  P.:  "De  I'sclerose,  tb.  du  pane,"  comp.  Rend,  ac  de  le,  Paris,  1897. 
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Chevassu:  Bull,  de  la  Soc.  Anat.,  1902. 
Chiari:  Miinch  med.  Woch.,  1878. 

Coats,  Joseph:  Glasgow  Medical  Journal,  i886  vol.  xxvi,  p.  53. 
Durante:  VI  Congress,  April  16,  1889;  also  Polichnico,  vol.  v,  1898.    Gaz.  degli   Osped, 

May  3,  1900. 
Eisenhardt;  Diss.  Miinchen,  1891. 


300  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

Elliesen,  P.:  "Ueber  Multipel  Solitar  tuberkel  in  der  Lever,"  Erlangen,  1900. 
Eppinger:    "  Ueber  Tuberk.  des  Magens  und  des  Oesophagus,"  Prag.   med.  Woch., 

1881,  Nos.  51,  52. 
Fletcher,  H.  M.:  "Tubercular  Cavities  in  the  Liver,"  Trans.  Path.  Soc.  London,  1898- 

99,  p.  7,  160  and  175. 
Fletcher:  Trans.  Path.  Soc.  London,  1899,  vol.  1,  p.  160. 

Frank,  L.:  "Primary  Tuberculosis  of  the  Liver,"  American  Journal  Med.  Sci.,  1902,  630, 
Gaubitt:  "Ueber  Magen  Tuberc."     Inaug.  Diss.,  Kiel,  1901. 
Ginger,  S.  G.:  "Experimental  T.  b.  c.  of  the  Liver,"  St.  Petersburg,  1902. 
Godart:  La  PoHchnique,  1901,  p.  183;  ibid.,  1904,  p.  481. 
Haberer:  "Ueber  ein  seltener  Fall  von  Magen  und  Darmstenose,"    1897,  Review   in 

Zentralblatt  fur  Chir.,  1905,  p.  1368. 
Hilgenreiner:  "Die  Erworbenen  fisteln  des  Magen  Darm  Kanals,"  Deutsch.    Chir.,  1905. 
Holmes:  Annals  of  Surgery,  vol.  xliii,  1906,  p.  800. 
Italia,  F.  E.:  "Pane.  E.  tuberculose  PoUcIin,"  Rome,  1900,  1901. 

Jacobs:  "Stenose  du  pylore  par  localizations  tuberc,"  Prog.  Med.  Belg.,  1900.     Re- 
print, Centralblatt  fur  Chir.,  1901,  No.  26. 
Kiihl:  "Ueber  Tuberc.  Magen  Geschweire,"  Inaug.  Dis.,  Kiel,  1889. 
Lancereaux:  Traits  de  Malad.  de  la  foie,  1899. 

Lannelongue:  "Tub.  h^patique  et  peri  hepat.  hepatotome  Cong.,"  1888. 
Laubry,  C. :  "Les  hepat.  tbc.  Int.  Medicale,"  1902,  p.  266. 
Lava  and  Orlandi :  Gaz.  Med.  df  Torino,  1893. 
Lefas,  E.:  "Etude  Anat.  de  I't,  b.  du  Pane,"  Arch.  Gen.  de  Med.,  Paris,  1900,  vol.  vii, 

1057. 
Le  Simple:  "Contrib.  a  I'^tude  des  Absces  tbe.  au  foie,"  Paris,  1900. 
Letorey:  "Contribution  a  I'^tude  des  ulceration  tuberc.  des  estomai ,"  These  de  Paris, 

1895. 
Leven:  " Gastrectasie  due  a  une  Compression  de  pylore,"  etc.,  Bull,  de  la  Soc.  Anat., 

Feb.,  1901. 
Litten:  Virchow's  Archiv,  Bd.  67,  1876. 
Loheac,  J.:  "Tuberc.  du  pancreas,"  Paris,  1899. 

Mackenzie,  H.  W.:  "Tubercular  Dis.  of  the  Liver,"  Trans.  Path. Soc,  London.,  1889-90. 
Marfan:  Th^se  de  Paris,  1887. 
Mathieu  and  Remond:  Th^se  Letorey. 
Mathieu:  "Ulc  tuberc  de  I'estomac,"  Prog.  Med.,  1882. 
Maylard:  "Abdominal  Tuberculosis,"  1908. 
Moore,  F.  C:  Munch,  med.  Chronicle,  May  19, 1899. 

Nordmann:  "Zur  Chir.  des  Magen-Geschwiilste,"  Arch,  fiir  klin.  Chir.,  Bd.  73. 
Oppolzer:  Med.  Presse,  1867,  Nos.  50  and  51. 
PaUier,  E.:  "Tuberc.  du  Pancreas,"  Paris,  1892. 
Patella:  "Delle  Stenosi,  piloriche  nei  Tuberc." 
Petruschky:  "Zur  diag.  und  Therap.  des  primaren  ulc.  vent.  Tuberc,"  Deutsch  med. 

Woch.,  1899,  vol.  ix. 
Poncet  and  Leriche:  Academie  de  Med.,  May  30,  1905. 
Reed:  "Tuberc.   Ulcerations  in  Stomach.      The  Use  of  Tuberculin."     International 

Med.  Mag.,  N.  Y.,  1900,  vol.  ix,  p.  197. 
Reinhold:  Inaug.  Diss.,  Kiel,  1899. 

Reverseau,  D.:  "Contrib.  a  I'^tude  des  pyo.  perihepatites  tuberculeuses,"  Paris,  1895. 
Reymond:  "Peritonite  localis^e,"  etc.,  Bull,  de  la  Soc.  Anat.,  1894. 
Ricard  and  Chevrier:  "Tuberculeuse  du  pylore,"  Rev.  de  Chir.,  1905,  Nos.  5,  6,  7. 
Robson,  Mayo:  Clin.  Soc.  of  London,  1895,  vol.  xxxiii. 
Rome:  Annals  of  Surgery,  1904,  vol.  xxxix,  p.  98. 

Ruge:  "Ueber  primare  Magentuberculose,"  Beitrag  fiir  klin.  der  Tuberc,  Bd.  iii.  No.  3. 
Sergent:  Th^se  de  Paris,  1895. 

Sholomorich,  A.:  "Primary  t.  b.  of  Pane,"  Kurzen,  Med.  Jour.,  1904,  373. 
Sigg,  E.:  "Ueber  Conglomerat  tuberculose  der  leber,"  Zurich,  1901. 
Simmonds:  "Ueber  Tuberc.  des  Magens,"  Miinch.  med.  Woch,  1900,  Nos.  7,  8,  and  10. 
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Soboleff,  L.  v.:  Virchow's  Archiv,  1904,  No.   177,  supplementary  volume,  p.   123-8. 
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Waring:  "Diseases  of  Liver,  etc  (Mayo  Robson  and  Moynihan,  "Dis.  of  Liver,"  etc.) 


LA  CURE  D'ALTITUDE  ET  LA  CURE  SOLAIRE  DE  LA 
TUBERCULOSE  CHIRURGICALE. 

Dr.  Rollier, 

Leysin,  Switzerland. 


En  1903  nous  avons  install^  a  installe  k  Leysin,  dans  les  Alpes  Vaiidoises 
Suisses,  le  premier  etablissement  destin^  exclusivement  au  traitement  de 
la  tuberculose  chirurgicale  par  la  cure  d'altitude  et  la  cure  solaire. 

Encourage  par  les  excellents  resultate  obtenus  par  la  cure  d'altitude 
de  la  tuberculose  pulmonaire,  nous  avons  resolu  de  faire  beneficier  nos 
tuberculeux  chirurgicaux  des  memes  facteurs  climateriques,  en  placant  leur 
organisme  dans  les  conditions  iddales  de  defense  qu'offre  la  haute  montagne. 
A  une  technique  therapeutique  conservatoire  nous  associons  un  tratement 
hygienique  intense,  le  grand  air  et  le  soleil  visant  ainsi  avant  tout  a  une 
refection  complete  du  terrain  tuberculeux.  Par  un  entrainement  indi- 
viduel  et  progressif  nous  amenons  tous  nos  malades  a  vivre  toute  I'annee 
a  I'air  libre.  Des  le  matin  tous  les  lits  sont  roules  sur  des  terrasses  d^ 
couvertes  ou  les  malades  b^n^ficent  sans  interruption  de  I'air  vivifiant  de 
I'Alpe. 

Par  le  meme  entrainement  nous  les  soumettons  a  Taction  tonifiante, 
reg6neratrice  et  bactericide  du  soleil  dont  I'intensit^  extraordinaire  est 
un  des  facteurs  curatifs  essentiels  du  climat  d'altitude.  Des  conditions 
climat^iiques  exceptionnelles  permettent  I'insolation  pendant  I'hiver 
comme  pendant  Tete.  Le  bain  de  soleil  a  I'altitude  n'incommode  jamais 
les  malades.  II  est  aussi  essentiel  comme  traitement  general  que  comme 
traitement  local.  II  produit  sur  I'organisme  un  effet  tonifiant  et  vivifiant 
remarquable  que  Ton  ol^tient  avec  aucune  autre  m^thode.  Nous  avons 
constate  que  la  force  de  resistance  d'un  malade  est  proportionelle  au  degr^ 
de  sa  pigmentation.  L'effet  local  et  de  I'insolation  sur  r6volution  de  la 
tuberculose  chirurgicale  est  encore  plus  remarquable  que  l'effet  general. 

L'action  bactericide  de  la  radiation  solaire  est  cliniquement  et  scien- 
tifiquement  d^montr^e.  EUe  est  due  pour  la  plus  grande  part  aux  rayons 
infra-rouges  et  aux  ultra-violets.  Le  pigment  provoqu^  par  ces  derniers 
transforme  ces  memes  rayons  ultra-violets  en  rayons  k  courte  longuer 
d'ondes  et  en  infra-rouges.  Les  derniers  sont  directement  bactericides, 
lis  pen^trent  dans  la  profondeur  des  tissus  oCi  ils  produisent  ^galement  un 

301 


302  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

mouvement  hyperh^mique  vers  les  parties  malades,  ou  ils  activent  la  phago- 
cytose.     L'intensite  de  ces  rayons  est  proportionelle  k  I'altitude. 

Un  des  premiers  symptomes  de  I'action  locale  de  la  cure  solaire  siir  la 
tuberculose  chirurgicale  est  son  effet  analgesiant.  II  se  manifesto  d'une 
facon  remarquable  dans  les  cas  de  coxalgies,  gonarthrites,  peritonites, 
cystites,  etc.,  ou  nous  avons  vu  la  douleur  rebelle  a  tout  autre  traitement 
disparaitre  ou  s'attenuer  apres  la  premiere  stance  d'insolation. 

Dans  les  cas  d'arthrites  telles  que  la  coxalgie  ou  la  gonarthrite  nous 
associons  I'insolation  a  une  immobilisation  severe  a  I'aide  d'appareils  platres 
que  nous  fenetrons  largement  au  siege  du  foyer. 

La  radiation  solaire  a  une  action  sclerosante  et  nettement  resolutive 
sur  les  adenites,  peritonites,  arthrites,  etc.  Sous  cette  action  les  oedemes 
et  les  infiltrations  disparaissent,  les  fongosites  s'affaissent,  et  se  sclerosent. 
Elle  donne  ^galement  les  meilleurs  resultats  dans  le  traitement  des  fistules 
qui  tarissent  d'autant  plus  rapidement  que  le  foyer  est  plus  superficiel. 
Elle  est  le  traitement  le  plus  rationel  de  toutes  les  plaies.  En  neutralisant 
Taction  des  germes  tout  en  sauvergardant  la  fonction  cellulaire  ce  proc6d6 
realise  les  conditions  essentielles  de  traitement  antiseptique  id^al.  L'helio- 
therapie  a  I'altitude  nous  parait  etre  le  traitement  de  choix  de  la  tuberculose 
chirurgicale.  Nous  n'avons  pas  encore  vu  une  seule  forme  de  tuberculose 
osseuse,  articulaire  ou  p^riton^ale  qui  n'ait  c^de  a  I'insolation.  Cette 
derniere  mieux  qu'aucune  autre  methode  permet  de  sauvergarder  la  fonc- 
tion articulaire.  Grace  k  la  refection  de  terrain  et  k  la  reconstitution  de 
I'organisme  elle  donne  les  meilleures  garanties  pour  I'avenir  du  malade. 
Nous  avons  communique  au  dernier  Congres  international  de  la  Tubercu- 
lose les  resultats  de  nos  premieres  observations  plaidant  avantageusement 
pour  ce  traitement.  Des  lors  Tobservation  de  plus  de  180  malades  est 
venue  confirmer  en  tous  points  notre  premiere  impression.  Nous  n'avons 
pas  la  pretention  apr^s  cinq  annees  d'experiences  d'apporter  ici  une  sta- 
tistique  concluante  nos  resultats  6tant  encore  trop  rapproch^s.  Nous 
citerons  seulement  les  chiffres  suivant  concernant  les  100  premiers  cas 
ayant  quitte  notre  etablissement  depuis  plus  de  2  ans: 

Malades  sortis 100  (dont  45  adultes). 

gu^ris 81  (dont  30  adultes). 

amelior^s 12  (dont    8  adultes). 

stationnaires 4  (dont    3  adultes). 

morts 3  (dont    3  adultes). 

Coxalgies 21  (dont  18  gu^ris). 

Maux  et  Pott 17  (dont  15  gueris). 

Gonarthrites 11  (dont  9  gueris). 

Ad^nites 11  (dont  8  gu6-is). 

Peritonites 7  (dont  5  gueris). 

Tuberculose  du  coude 4  (dont  4  gueris). 

Tuberculose  du  pied 3  (dont  3  gu<5ris). 

Tuberculose  du  poignet 3  (dont  3  gueris). 


THE  ACUTE  FORMS  OF  ABDOMINAL  TUBERCULOSIS. 

By  Daniel  N.  Eisendrath,  A.B.,  M.D., 

Professor  of  Surgery,  College  of  Physicians  and  Surgeons,  Attending  Surgeon  to  the  Michael  Reese 
and  Cook  County  Hospital,  Chicago. 


There  has  been  a  general  impression  for  many  years  in  the  minds  of  the 
profession  that  tuberculosis  of  the  various  abdominal  structures  was  a 
disease  which  almost  invariably  began  in  a  slow,  insidious  manner. 

That  the  lesions  caused  by  the  tubercle  bacillus  are  often  accompanied 
by  such  acute  symptoms  as  to  simulate  in  every  detail  the  well-recognized 
acute  forms  of  disease  of  the  various  abdominal  viscera  is  not  as  well  known 
as  it  deserves  to  be. 

The  two  structures  which  are  most  apt  to  be  thus  involved  are  the  appen- 
dix and  the  peritoneum,  and  the  present  paper  will  be  limited  to  these  two. 
Mayo,^  however,  has  called  attention  to  such  an  acute  onset  in  cases  of 
tuberculosis  of  the  Fallopian  tube,  and  the  WTiter,  in  a  previous  paper,  has 
emphasized  the  relative  frequency  with  which  a  mixed  gonococcus  and 
tuberculous  infection  of  the  epididymis  will  be  accompanied  by  very  acute 
symptoms. 

My  interest  in  the  subject  was  reawakened  by  an  experience  during  the 
summer  of  1907.  A  near  relative  of  the  writer,  a  boy  of  eight,  while  traveling 
in  Switzerland,  was  taken  suddenly  ill,  while  apparently  enjoying  the  best 
of  health.  He  began  to  have  vague  abdominal  pains,  accompanied  by  per- 
sistently high  temperature  (to  105°  F.)  of  a  continuous  type,  with  symptoms 
of  marked  prostration.  Upon  the  third  day  there  was  tenderness  over  the 
right  iliac  region  and  a  distinct  mass  to  be  palpated.  The  diagnosis  of  acute 
appendicitis  was  made  by  the  local  physician  and  confirmed  by  Professor 
Theodore  Kocher,  of  Berne,  to  whom  the  writer  wishes  to  express  his  thanks 
for  permission  to  include  the  case  in  the  present  paper.  The  abdomen  was 
opened  by  Professor  Kocher  upon  the  fifth  day  of  the  illness,  and  a  large 
mass  exposed  in  the  ileocecal  angle,  which  was  at  first  thought  to  be  an 
acutely  inflamed  appendix  wrapped  in  omentum.  Further  examination 
showed,  however,  that  this  mass  was  composed  of  four  or  five  greatly  enlarged 
ileocecal  lymph-nodes,  each  about  the  size  of  a  hazelnut.  One  of  these  nodes 
was  excised,  and  showed  upon  section  all  the  evidence  of  an  acute  inflamma- 
tion, but  contained,  in  addition,  a  number  of  recent  caseous  foci. 

303 


304  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

The  remainder  of  the  larger  nodes  were  excised  and  the  appendix  care- 
fully examined.  It  showed  only  acute  catarrhal  changes,  but  was  removed. 
Microscopical  examination  of  the  lymph-nodes  and  appendix  confirmed  the 
diagnosis  of  tuberculosis.  The  appendix  showed  several  typical  submucous 
tubercles,  and  the  nodes  showed  all  the  characteristic  evidences  of  tubercu- 
lous infection. 

The  child  made  a  slow  recovery,  the  most  marked  symptoms  of  the 
convalescence  being  great  weakness,  emaciation,  and  anemia.  During  the 
past  year  the  child  has  gained  greatly  in  weight  and  strength,  and  seems  to 
have  made  a  complete  recovery. 

Professor  Kocher  expressed  the  opinion  that  the  appendix  had  unques- 
tionably been  the  atrium  of  infection,  and  that  the  case  had  been  one  of 
tuberculous  appendicitis  due  to  the  ingestion  of  butter  containing  tubercle 
bacilli.  This  patient  had  not  taken  milk  in  any  form  for  several  years,  so 
that  infection  from  this  source  could  be  excluded. 

After  reflecting  upon  this  case  and  looking  over  his  own  records  and  the 
literature  of  the  subject  for  similar  cases,  the  writer  has  thought  it  desirable 
to  direct  attention  to  these  cases  of  acute  onset  of  tuberculous  appendicitis 
and  peritonitis. 

There  are  but  few  statistics  available  as  to  the  frequency  of  primary 
tuberculous  infection  of  the  appendix.  Fenwick  and  DodwelP  found  that 
the  appendix  was  the  only  portion  of  the  alimentary  tract  involved  in  17  of 
2000  autopsies  upon  phthisical  patients.  Leseur,^  in  144  examples  of  tuber- 
culous appendicitis,  observed  at  autopsies  of  phthisical  patients,  found  no 
other  lesion  than  that  of  the  appendix  in  12.  The  opinion  is  rapidly  gaining 
ground  that  primary  tuberculous  infection  of  the  alimentary  tract  is  not  as 
infrequent  a  condition  as  was  formerly  thought. 

The  chief  sources  of  infection  are  the  ingestion  of  milk,  butter,  and  cheese 
from  tuberculous  cows.  The  danger  from  the  meat  of  cattle  and  hogs  is 
much  less  than  that  from  milk  and  its  products.  That  milk  can  act  as  a 
carrier  of  infection  is  so  generally  accepted  that  it  will  be  unnecessary  to 
dwell  upon  it  here.  It  is,  however,  a  matter  of  the  greatest  importance  to 
be  awake  to  the  fact  that  butter  is  as  potent  a  means  of  conveying  tubercle 
bacilli  from  animals  to  man.  This  has  recently  been  the  subject  of  an  inves- 
tigation by  the  U.  S.  Department  of  Agriculture.  The  position  of  those  who 
hold  for  infection  by  ingestion  seems  much  fortified  by  the  findings  of  E.  C. 
Schroeder  and  W.  E.  Cotton,  of  the  experiment  station  service  in  Washington, 
set  forth  in  Circular  127, ^  entitled  "Tubercle  Bacilli  in  Butter."  The 
authors  consider  that  "a  very  large  amount  of  butter  infected  with  tubercle 
bacilli  is  daily  consumed  by  our  people,"  that  this  food  is  an  ideal  environ- 
ment for  the  preservation  of  this  bacterium.  After  ninety  days  these  germs 
show  only  a  doubtful  reduction  of  pathogenic  virulence.    They  tend  to  sep- 


ACUTE    ABDOMINAL   TUBERCULOSIS. EISENDRATH.  305 

arate  themselves  from  the  milk  by  rising  with  the  cream  or  precipitating 
with  the  sediment.  Consequently,  these  are  the  parts  of  milk  which  are  most 
intensely  infected.  Butter  probably  contains  them  in  discernible  numbers, 
"13  times  for  every  10  times  they  are  sufficiently  numerous  in  milk  to  be 
detected."  These  workers  further  declare  that  from  15  per  cent,  to  30  per 
cent,  of  the  cows  from  which  our  cities  draw  their  milk-supply  are  affected 
by  tuberculosis;  that  about  one-fourth  of  the  samples  of  sediment  taken 
from  the  cream  separators  of  public  creameries  throughout  the  country  show 
tubercle  bacilli;  and  that  the  frequency  with  which  these  bacilli  occur  in 
the  sediment  from  milk  is  a  fair  measure  of  their  frequency  in  cream,  from 
wliich  butter  is  made.  "Pleasure  for  measure,  infected  butter  is  a  greater 
tubercular  danger  than  infected  milk."  Furthermore,  because  of  the  shield 
offered  by  butter  against  the  germicidal  action  of  sunlight,  it  tends  ideally 
for  their  preservation;  and  tests  show  that  in  ordinary  salted  butter  of  com- 
merce the  Koch  bacillus  "may  live  and  retain  virulence  practically  four  and 
a  half  months  or  longer." 

In  the  majority  of  text-books  brief  reference  is  made  to  the  fact  that 
tuberculosis  of  the  appendix  and  peritoneum  may  begin  acutely.  The  case 
just  described  and  the  following  ones  to  be  reported  certainly  show  that  such 
an  acute  onset  is  a  factor  to  be  considered  in  the  future  when  we  are  called 
upon  to  diagnose  the  nature  of  an  acute  abdominal  affection. 

The  French  surgical  journals  have  recently  contained  reports  of  some 
extremely  instructive  cases  of  which  I  will  first  give  a  synopsis. 

Case  of  A.  Demoulin.*  Female,  aged  thirty-eight,  had  her  first  attack  of 
acute  pain  in  the  right  iliac  region  in  July,  1904.  A  second,  but  more  severe, 
attack  occurred  in  November,  1905.  She  was  seen  by  Demoulin  in  January, 
1906,  during  her  third  attack.  There  was  a  great  tenderness  over  McBurney's 
point  and  a  hard  mass  to  be  felt.  After  subsidence  of  the  acute  symptoms 
operation  on  February  15,  1906,  revealed  a  mass  of  lymph-nodes  the  size 
of  a  hen's  egg  in  the  ileocecal  angle.  Some  of  these  were  hard,  others  caseous. 
These  nodes  and  the  appendix  were  removed.  The  examination  of  the 
appendix  was  negative.  The  patient  was  well  fourteen  months  after  the 
operation. 

The  first  French  surgeon  to  call  attention  to  the  fact  that  a  pericecal 
tuberculous  adenitis  can  give  rise  to  symptoms  of  acute  appendicitis  was 
Gerard-Marchant.'^  He  also  emphasized  the  fact  that  a  tuberculous  appen- 
dicitis could  exist  without  either  microscopical  or  macroscopical  evidence  of 
its  specific  nature,  the  only  evidence  being  the  tuberculous  ileocecal  lymph- 
nodes.  This  view  of  Gerard-Marchant  has  since  been  indorsed  by  other 
European  surgeons,  especially  in  France,  and  is  in  accordance  with  the 
experimental  evidence  furnished  by  Dobroklonsky^  in  1890.  The  latter 
showed  conclusively  that  tubercle  bacilli  can  pass  through  the  healthy  in- 


306  SIXTH   INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

testinal  wall  without  leaving  any  trace  of  their  migration.  Tliis  is  analogous 
to  what  is  frequently  observed  in  the  tonsil. 

The  case  of  Gerard-]\Iarchant  was  as  follows:  A  young  Cuban  had  two 
classical  attacks  of  what  was  diagnosed  as  acute  appendicitis,  with  pain  in 
the  right  iliac  region,  fever,  vomiting,  and  tympany.  The  fever  and  a  tumor 
in  the  right  iliac  region  persisted.  At  operation  two  caseous  ileocecal  nodes 
were  found,  and  these  and  the  appendix  were  removed.  The  appendix 
showed  no  changes  either  to  the  naked  eye  or  upon  microscopical  examination. 
In  a  case  of  Lecene  (quoted  by  Petit^  there  was  a  similar  history  and  three 
tuberculous  nodes  were  found  in  the  mesoappendix.  The  appendix  showed 
submucous  tubercles  microscopically.  In  all  these  cases  the  lymph-nodes 
may  be  the  principal  lesion,  although  the  appendix  is  the  atrium  of  infection. 

Routier^  reports  a  case  where  the  appendix  was  large,  red,  and  adherent, 
and  the  nodes  were  large  and  tuberculous. 

In  Siredey's^  case  a  female  of  fourteen  who  had  a  tuberculous  father  had 
always  enjoyed  good  health.  She  had  frequent  attacks  of  colicky  pain  in 
the  right  iliac  region,  the  diagnosis  of  chronic  appendicitis  being  made  by 
Jalaguier.  At  operation  a  straw-colored  fluid  escaped.  There  were  many 
miliary  tubercles  scattered  over  the  peritoneum.  The  appendix  was  re- 
moved, but  showed  only  the  changes  characteristic  of  a  chronic  appendicitis. 
A  large  lymph-node  removed  from  the  mesoappendix  contained  caseous  foci. 

Tuffier^'^  has  recently  reported  a  case  of  Guibal  and  one  of  his  own  which 
are  quite  typical.  In  Guibal's  case  a  previously  healthy  child  of  six  began 
suddenly  to  have  severe  abdominal  pain,  accompanied  by  marked  right- 
sided  rigidity  and  tenderness,  fever  to  103°  F.,  and  vomiting.  Appendec- 
tomy was  performed  four  weeks  later  during  the  interval.  Ileocecal  nodes, 
the  size  of  a  large  nut,  showing  many  caseous  foci,  were  found  and  removed. 
The  peritoneum  and  cecum  were  negative.  The  appendix  showed  no  tuber- 
culous changes. 

In  Tufher's  own  case,  a  girl  of  twelve  was  operated  on  two  months  after 
a  typical  attack  of  acute  appendicitis.  The  appendix  showed  a  tuberculous 
folliculitis  and  there  were  several  caseous  ileocecal  nodes  which  were  also 
removed. 

A  case  similar  to  those  just  quoted  occurred  during  the  past  summer  in 
the  Michael  Reese  Hospital  sei-vice  of  my  colleague,  Dr.  Louis  A.  Greens- 
felder,  to  whom  I  am  indebted  for  permission  to  pubhsh  it  here. 

L.  T.,  girl  aged  five,  was  admitted  to  the  service  of  Dr.  Greensfelder 
June  2,  1908.  Parents  both  living  and  in  good  health.  Patient  is  the  only 
child;  well  nourished,  taken  ill  suddenly  the  day  preceding  her  admission 
with  pains  in  abdomen  and  left  side  of  chest.  Had  been  apparently  in  best 
of  health  prior  to  onset  of  present  illness.  Examination  upon  admission 
showed  a  small  area  of  consolidation  in  upper  lobe  of  left  lung. 


ACUTE    ABDOMINAL   TUBERCULOSIS. — EISENDRATH.  307 

The  abdomen  was  somewhat  tympanitic,  quite  rigid,  and  there  was 
general  tenderness  on  pressure,  but  this  was  marked  in  the  right  ihac  region. 
Upon  opening  the  abdomen  a  free  straw-colored  fluid  escaped.  The  glands 
in  the  meso-appendix  were  greatly  enlarged  and  caseous.  The  appendix 
was  injected  and  thickened.  Appendectomy  and  removal  of  glands.  No 
microscopical  examination  of  the  appendix  was  made.  Recovery  from 
operation  and  discharge  from  hospital  on  July  19,  1908, 

The  following  cases  of  acute  tuberculous  peritonitis  occurred  in  the 
service  of  the  writer. 

Case  1. — Encapsulated  (subphrenic)  tuberculous  peritonitis  with  veiy 
acute  onset  simulating  ordinary  subphrenic  abscess. 

V.  de  S.,  male,  forty-eight  years  of  age,  was  admitted  on  August  24,  1906, 
to  the  medical  servdce  of  Dr.  J.  L.  Miller,  in  the  Cook  County  Hospital,  with 
the  diagnosis  of  pneumonia.  On  account  of  the  patient's  inability  to  speak 
English  well,  the  only  history  obtainable  was  that  he  had  been  perfectly 
well  up  to  nine  days  before  admission,  when  he  began  to  have  pain  in  the 
abdomen  wliich  varied  greatly  in  intensity  and  was  most  marked  around  the 
umbilicus.  The  leukocjdie  count  was  8600,  the  abdomen  distended,  and  the 
temperature  ranged  between  100°  F.  and  104°  F.  The  condition  remained 
unchanged  for  ten  days.  Owing  to  the  fact  that  the  rigidity  and  tenderness 
were  most  marked  in  the  right  hypochondrium,  a  diagnosis  of  acute  chole- 
cystitis was  made,  and  he  was  transferred  to  the  surgical  service  of  Dr. 
Charles  Hej^^ood.  The  latter  opened  the  abdomen,  and  the  appendix  and 
gall-bladder  were  found  normal.  There  were,  however,  many  dense  adhes- 
ions between  the  coils  of  intestine,  and  the  omentum  was  adherent  to  the 
abdominal  wall.  After  this  operation  the  temperature  rose  still  higher  (to 
104-4°  F.),  and  there  was  accompanying  stupor,  dehrium,  and  rapid  respir- 
ations (to  44). 

In  the  absence  of  Dr.  Hey^v'ood  the  patient  was  seen  by  the  writer  on 
September  6,  1906.  There  was  a  marked  stupor,  there  was  dullness  extend- 
ing upward  from  the  liver  to  the  fourth  rib  in  the  mammary  line,  to  the  fifth 
rib  in  the  midaxillary  line,  and  seventh  rib  in  the  scapular  line.  There  was 
an  absence  of  respiratory  sounds  over  this  area.  Upon  inserting  an  explor- 
ing needle  through  the  eighth  interspace  a  foul  flaky  fluid  was  obtained. 
The  eighth  rib  was  resected  in  the  scapular  line,  and  the  pleural  cavity  found 
empty.  The  diaphragm  was  sutured  to  the  parietal  wound,  and  about  twelve 
ounces  of  a  slightly  turbid  fluid  evacuated  from  the  suljphrenic  space.  The 
patient  made  a  slow  recovery,  the  subphrenic  wound  continuing  to  discharge 
for  several  weeks.  About  eight  weeks  later  evidence  of  marked  ascites  ap- 
peared, and  patient  died  about  six  months  later.  The  autopsy  showed  a 
typical  tulDerculous  peritonitis  with  effusion.  The  subphrenic  region  showed 
firm  adhesions  over  the  previously  involved  area. 

Case  2. — A.  L.  W.,  aged  twenty-six  years,  clerk.  Had  always  enjoyed 
good  health.  Family  history  negative.  Present  illness  began  suddenly  in 
February,  1904,  with  pain  in  right  iliac  region,  but  no  fever.  A  physician 
who  saw  him  at  the  time  made  a  diagnosis  of  appendicitis.  When  first  seen 
by  the  writer  in  June,  1904,  there  were  evidences  of  an  encapsulated  collec- 
tion of  fluid  in  the  right  iliac  region.     Laparotomy  revealed  a  walled-off 


308  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

collection  of  thin  yellowish  pus  occupying  the  right  half  of  the  abdomen. 
The  posterior  wall  of  this  abscess  cavity  was  formed  by  agglutinated  coils 
of  intestines  covered  with  tubercles  and  granulation  tissue  which  showed 
evidences  of  tuberculosis  microscopically.     Complete  recovery. 

Case  3. — Acute  onset  of  tubercular  peritonitis  with  high  continuous 
fever  resembling  typhoid.  A  female,  aged  thirty-five,  had  been  ill  five  weeks 
when  first  seen  by  the  writer.  The  illness  had  begun  suddenly  with  mild 
abdominal  pains  and  other  vague  symptoms  like  a  typhoid.  Her  fever  had 
been  of  the  continuous  type,  and  ranged  between  101°  and  104°  F.  She  had 
been  given  the  routine  typhoid  treatment.  Examination  by  the  writer 
showed  evidences  of  fluid,  and  laparotomy  revealed  a  very  advanced 
ulcerative  caseous  peritonitis.  An  example  of  such  an  acute  onset  is  shown 
in  the  recent  report  of  a  case  by  A.  K:  Stone." 

Case  4. — Female,  aged  twenty-two  years,  mother  died  of  phthisis,  was  ad- 
mitted to  the  Massachusetts  General  Hospital  in  February,  1907.  Her  illness 
had  begun  suddenly  three  days  before  admission,  with  severe  abdominal  pain 
and  vomiting.  Upon  admission  the  abdomen  was  found  to  contain  free 
fluid,  accompanied  by  rigidity  and  tenderness.  The  evidences  of  fluid  dis- 
appeared under  medical  treatment.  Stone  states  that  sudden  onset  is 
common  in  tuberculous  peritonitis,  being  found  in  about  one-quarter  of  all 
cases,    The  fluid  both  accumulates  and  disappears  rapidly. 

Osier  refers  briefly  to  the  fact  that  tuberculous  peritonitis  may  begin 
suddenly  and  be  accompanied  by  continuous  fever,  resembling  that  of 
typhoid  fever.  The  absence  of  the  Widal  reaction,  the  leukopenia,  and  not 
infrequently  the  evidences  of  the  presence  of  free  fluid  will  serve  to  dis- 
tinguish the  process  as  a  tuberculous  one. 

A  case  is  reported  by  Michaux,^^  resembling  my  own,  of  an  acute  onset 
of  tuberculous  peritonitis  with  symptoms  pointing  to  a  subphrenic  abscess. 
In  Michaux's  case  the  onset  was  very  sudden,  with  great  dyspnea  resembling 
a  pneumothorax  clinically.  There  was  high  temperature,  and  edema  over 
the  right  side  of  the  abdomen  and  chest-wall.  An  incision  along  the  costal 
arch  evacuated  pus  containing  gas.  There  was  temporary  improvement, 
as  in  the  writer's  case,  but  death  occurred  one  month  later.  The  autopsy 
showed  a  dry  tuberculous  peritonitis. 

The  most  complete  statistics  upon  tuberculous  appendicitis  are  those  of 
Brunner,^  based  upon  51  cases  collected  from  the  literature.  It  includes  all 
published  cases  in  which  appendectomy  had  been  performed.  To  this 
number  I  can  now  add  7.  Of  these  59  cases  nearly  one-fourth,  i.  e.,  16,  had 
symptoms  which  in  every  detail  resembled  an  attack  of  acute  appendicitis. 
The  direct  operative  mortality  in  this  series  of  59  cases  has  been  very  small. 
It  is  almost  impossible  to  state  what  the  final  results  have  been,  because  so 
few  of  the  cases  have  been  followed  for  a  sufficient  time  to  speak  of  a  com- 
plete recovery,  and  in  many  of  the  reports  the  patients  suffered  from  tu- 
berculous lesions  elsewhere  which  ultimately  resulted  fatally. 


ACUTE    ABDOMINAL   TUBERCULOSIS. — EISENDRATH.  309 

If,  however,  in  such  cases  as  those  of  the  French  surgeons  just  quoted 
and  of  Kochcr's  and  Greensfelder's,  the  lesion  is  operated  upon  early  enough, 
and  the  appendix  and  glands  removed,  the  prognosis  should  be  very  favor- 
able. That  the  appendix  in  many  of  the  cases  showed  no  tuberculous 
changes  does  not  mihtate  against  such  a  specific  infection.  As  stated  above, 
the  tubercle  bacilli  can  pass  through  the  walls  of  the  appendix  without 
leaving  any  trace  of  their  passage.  The  bacilli  can  then  infect  the  ileocecal 
lymph-nodes,  or  be  the  starting-point  of  a  tuberculous  peritonitis. 

My  conclusions  are  the  following: 

1.  That  a  primary  tuberculous  appendicitis  is  not  as  rare  an  affection  as 
was  formerly  thought. 

2.  That  such  an  infection  can  be  followed  by  secondary  involvement  of 
the  ileocecal  lymph-nodes  which  is  out  of  all  proportion  to  the  pathological 
changes  in  the  appendix. 

3.  In  the  majority  of  cases  there  are  evidences  of  tuberculous  foci  in  the 
appendix,  but  secondary  caseous  lymph-nodes  may  be  found  without  visible 
macroscopical  or  microscopical  tuberculous  changes  in  the  appendix. 

4.  Butter,  milk,  and  cheese  from  tuberculous  cows  are  the  chief  sources 
of  infection  in  primary  intestinal  tuberculosis. 

5.  In  a  fair  proportion  of  the  59  published  cases  (27  per  cent.)  of  tuber- 
culous appendicitis  the  clinical  picture  resembled  that  of  an  acute  non- 
tuberculous  appendicitis.  No  statistics  are  available  to  estimate  the  pro- 
portion of  cases  of  tuberculous  peritonitis  which  begin  acutely,  but  the 
number  is  larger  than  it  is  usually  thought  to  be. 

6.  Through  early  diagnosis  and  radical  removal  of  the  tuberculous  appen- 
dix and  infected  lymph-nodes  (as  far  as  practicable)  complete  and  permanent 
recovery  can  occur.  Some  of  the  cases  of  ileocecal  tuberculosis  and  of 
tuberculous  peritonitis  may  thus  be  avoided  through  removal  of  the  probable 
starting-point. 

BIBLIOGRAPHY. 

1.  Mayo:  Jour.  Amer.  Med.  Assoc,  April  15,  1905. 

2.  Brunner:  "Deutsche  Chirurgie,"  vol.  xlvi,  e. 

3.  Schroeder  and  Cotton:   Report  127  of  the  Bureau  of  Animal  Industry,  Department 

of  Agriculture. 

4.  Demoulin:  Bull,  et  Mem.  de  Soc.  de  Chirurgie  de  Paris,  May  15,  1907. 

5.  Gerard-Marchant:  Same  as  above,  January  24,  1900. 

G.  Dobroklonsky:  Archives  de  M6d.  exp6r.  et  d'anat.  Path.,  No.  2,  1890. 

7.  Petit:  Dissertation  de  Paris,  1905. 

8.  Routier:  Bull,  et  mem.  de  Soc.  de  Chirurgie,  July  5,  1905. 

9.  Siredey:  Same  as  above,  May  15,  1907. 

10.  Tuffier:  Same  as  above,  May  29,  1908. 

11.  Stone:  Boston  Med.  and  Surg.  Jour.,  May  16,  1908. 

12.  Michaux;  Bull,  et  Mem.  de  Soc.  de  Chirurgie,  1897 


310  SIXTH    INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

DISCUSSION. 

Dr,  Gregory  Connell  (Oshkosh,  Wisconsin)  said  the  term  acute  tuber- 
cular appendicitis  was  misleading,  as  it  was  evident  from  the  history  of  the 
cases  that  the  condition  was  that  of  a  tubercular  appendicitis  upon  which 
there  had  been  ingrafted  an  acute  process  which  caused  the  symptoms  which 
led  to  the  diagnosis.  A  tubercular  process  was  essentially  chronic,  rarely 
acute,  and  the  fact  that  caseous  degeneration  had  taken  place  in  the  glands 
of  the  mesentery  would  lead  one  to  believe  that  such  was  the  case.  Out  of 
300  cases  of  appendicitis  examined  during  the  past  year  he  Tiad  found  only 
one  that  was  tuberculosis. 

Dr.  H.  G.  Nierman  (Fort  Wayne,  Indiana)  said  it  had  been  demonstrated 
that  food  taken  into  the  stomach  passed  through  the  intestinal  tract  more 
rapidly  in  the  beginning,  and  its  movement  become  slower  and  slower  the 
farther  down  it  went.  The  intestinal  flora  increase  in  proportion  as  the 
movement  of  the  food  becomes  slower.  Stagnation  tends  to  produce  disease. 
The  condition  of  the  appendix  particularly  favored  the  growth  of  bacteria. 
In  the  treatment  of  certain  of  the  cases  mentioned  he  suggested  that  it  might 
be  well  to  perform  anastomosis  between  the  ileum  and  the  descending  colon, 
thus  cutting  out  the  diseased  portion. 

Dr.  Beck  said  he  would  like  to  ask  Dr.  Bevan  whether  he  removed  part  of 
the  ureter  in  performing  nephrectomy  when  it  was  found  to  be  tuberculous. 

Dr.  Bevan,  in  closing,  said  he  thought  the  rule  should  be  to  dissect 
the  ureter  out  as  widely  as  possible  without  adding  too  much  to  the  risk 
of  the  operation.  He  had  no  sympathy,  however,  with  Kelly's  proposition 
to  remove  the  entire  ureter  and  then  turn  the  stump  into  the  bladder.  He 
said  he  thought  the  most  important  work  in  connection  with  kidney  tuber- 
culosis should  be  done  by  the  internists.  Those  who  do  not  believe  in  the 
surgical  treatment  should  compare  the  results  of  general  hygienic  treatment, 
the  tuberculin  treatment,  and  the  surgical  treatment,  as  there  were  no 
statistics  available  comparing  these  different  methods. 

Dr.  EisENDRATH,  in  closing,  said  the  point  brought  out  by  Dr.  Connell 
was  not  a  debatable  one.  Wc  had  acute  tuberculous  pneumonia,  and  why 
not  an  acute  tuberculous  appendicitis? 


1^1 

^V.    1 

Kf,K^i»i  ^^^^^i^^^^^^^^^^^^^^i 

r*?^*^ 

■fl 

RATIONAL  SPINAL  SUPPORT. 
By  Henry  W.  Frauenthal,  A.  C,  M.D., 

Physician  and  Surgeon-in-Chief  of  the  Hospital  for  Deformities  and  Joint  Diseases,  New  York. 


The  orthopedist  has  been  slow  in  assimilating  into  the  treatment  of 
tuberculous  bone  lesions  the  many  valuable  truths  of  recent  scientific  de- 
velopment in  use  in  tubercular  processes  of  the  soft  tissues.  Tliis  paper  is  to 
call  attention  to  defects  in  conventional  mechanical  treatment  now  in  use. 

I  hope  to  be  able  to  demonstrate,  by  means  of  photographs  of  apparatus 
on  patients  that  are  herewith  presented,  that  fundamental  principles  of 
applied  mechanics  have  not  been  made  use  of  in  the  application  of  the 
braces  now  generally  in  use  in  tuberculous  disease  of  the  spine,  and  that  the 
bad  results  made  manifest  in  hideous  deformities  have  resulted  from  a 
fa,ilure  to  apply  such  scientific  principles  of  mechanics  in  the  fitting  of  braces, 
as  would  be  applied  in  other  mechanical  endeavor  (Cases  1,  2,  and  3),  all 
these  cases  being  under  treatment  from  the  time  that  disease  occurred, 
but  before  a  knuckle  was  evident,  until  the  deformity  developed. 

It  appears  to  me  that  we  have  an  imperialism  of  brace  apphcation 
without  fuU}^  determining  if  the  apparatus  would  properly  do  its  work  and 
render  such  fixation  and  support  to  the  spine  as  the  nature  of  the  disease 
requires. 

In  many  cases  we  see  braces  and  jackets  (plaster,  leather,  felt,  celluloid, 
etc.)  applied  to  prevent  increasing  deformity,  without  regard  to  its  mechanical 
function  in  the  given  case.  This  is  frequently  seen  when  the  disease  is 
above  the  seventh  dorsal  vertebra,  when  the  brace  or  jacket  is  applied  with- 
out the  addition  of  a  jury-mast. 

In  the  mechanical  treatment  of  tuberculous  joints  we  must  decide  which 
is  best — 

1.  Fixation. 

2.  Fixation  with  traction,  thus  tiying  to  separate  the  inflamed  surfaces 
and  prevent  the  aljsorption  produced  by  muscular  and  ligamentous  contrac- 
tion. 

3.  Traction  with  motion. 

If  we  wish  to  obtain  fixation,  our  support  must  be  such  as  to  permit  of  the 
least  possible  amount  of  motion. 

If  traction  is  to  be  added,  which  is  always  to  be  desired  in  disease  of  the 

311 


312  SIXTH    INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

body  of  the  vertebrae,  to  prevent  absorption  by  pressure,  our  support  must 
come  from  the  ground,  through  the  bony  framework  of  the  pelvis  and  ex- 
tremities. This  can  be  accomplished  only  by  the  brace  firmly  resting  on 
the  bony  framework  of  the  pelvis,  when  extension  can  be  made  by  the 
brace  itself  or  by  a  jury-mast.  The  former  is  simply  accomplished  by 
throwing  the  weight  on  the  transverse  processes  of  the  vertebrse.  This  can- 
not be  done  by  the  Taylor  brace,  Knight's  crib,  or  similarly  constructed 
apparatus,  as  they  attempt  to  rest  the  base  (x-y)  for  support  on  the 
gluteal  muscles  and  hold  it  fixed  by  means  of  an  apron.  This  result  is  a 
pressure  atrophy  of  the  gluteal  muscle. 

As  this  type  of  brace  has  been  in  vogue  for  such  a  long  time,  I  will 
now  point  out  its  mechanical  and  physiological  defects,  with  some  of  the 
common  results  shown  in  patients  treated  by  this  method. 

The  two  parallel  metal  bars  (S,  V,  S',  V)  that  extend  down  both  sides 
of  the  spine  are  attached  to  a  circular  band,  X-Y,  that  rests  on  the  gluteal 
muscles;  the  other  construction  of  the  brace  does  not  enter  into  the  mechan- 
ical principles  under  discussion. 

Resting  the  lower  band  of  the  brace  (X-Y)  on  a  child's  soft  gluteal  muscles 
must  result  in  the  brace  sliding  down  on  these  soft  tissues  and  merely  adding 
the  additional  weight  of  the  brace  to  the  superimposed  weight  above  the 
point  of  disease,  to  exaggerate  the  disease  by  increasing  weight  and  pressure. 

To  prevent  this  slipping,  the  second  error  in  treatment  and  mechanism 
has  been  made,  by  tightening  an  apron  about  the  chest  and  abdomen, 
with  the  result  that  it  is  about  soft  relaxing  tissue  that  cannot  be  fixed  in 
this  way,  only  constricting  the  abdominal  muscles  below,  interfering  with 
digestion,  often  producing  a  pressure  constipation  above,  the  apron  about 
the  chest  interfering  with  respiration  and  producing  imperfect  and  de- 
fective metabolic  processes  in  the  whole  enconomy.  The  pressure  pro- 
duced by  the  lower  bar  about  the  gluteal  muscles  (results  in  photos,  cases 
1,  2,  3)  produces  atrophy  of  these  muscles.  Thus  the  restriction  of  the 
apron  interferes  with  the  development  of  the  child  and  his  ability  to  build 
up  a  resistance,  to  throw  off  the  tuberculous  disease,  and  secondly,  the 
additional  weight  increases  deformity. 

By  this  I  mean  that  in  cases  seen  by  me,  in  which  nature's  cure  has 
resulted  without  the  aid  of  any  surgical  treatment,  the  bony  prominence  has 
given  less  deformity  than  the  hideous  deformed  backs  that  are  shown  in 
these  pictures  (1,  2,  3),  and  many  other  photographs  in  my  possession, 
where,  by  the  lowering  of  the  vitality,  by  the  restriction  of  the  apron,  and 
the  added  weight  of  the  brace,  these  unsightly  deformities  have  resulted. 

I  wish  now  to  draw  your  attention  to  a  brace,  carrying  a  collar  over  the 
crest  of  the  ilium  (Fig.  5),  giving  a  primary  bony  support,  through  the 
pelvis  and  leg,  to  the  ground.    This  support  does  away  with  the  necessity 


RATIONAL   SPINAL   SUPPORT. — FRAUENTHAL.  313 

of  an  apron,  and  permits  us  to  throw  the  superimposed  weight  back  on  the 
transverse  processes.  By  dispensing  with  the  apron,  the  lungs  and  heart  can 
be  developed,  and  the  digestive  function  is  unrestricted,  a  high  vitality  is 
kept  up  and  resistance  furnished  to  incapsulate  the  tuberculous  process. 

As  one  sees  so  frequently  tuberculous  disease  of  the  spine  above  the 
seventh  dorsal  vertebra,  it  must  rest  with  the  surgeon  whether  rest  on  a 
cuirass  or  ambulatory  treatment,  with  a  brace  or  jacket,  be  used,  but  in  the 
latter  case  it  is  imperative  to  attach  a  jury-mast,  as  the  jacket  alone  inter- 
feres with  the  child's  general  health  and  accomplishes  nothing  toward  a  cure. 

The  following  case  represents  one  of  the  type  seen  at  the  Hospital  for 
Deformities  and  Joint  Diseases  so  frequently  as  to  call  for  some  comment. 

A.  Mc,  referred  by  Dr.  DeKraft,  with  the  following  history:  In  Febru- 
ary, 1907,  the  child  complained  of  stomach  and  abdominal  pains,  and  on 
advice  of  another  tenant  in  the  house,  who  had  a  child  suffering  with  Pott's 
disease,  she  went  to  an  orthopedic  dispensary,  March  2,  1907,  where  a 
diagnosis  of  disease  of  the  dorsal  spine  was  made,  but  the  child  was  sent 
home  to  await  its  recovery  from  whooping-cough. 

She  returned  May  24,  1907,  for  the  first  jacket,  and  by  May  18,  1908, 
she  had  had  four  jackets  applied;  in  the  mean  time  she  was  kept  in  the 
Masonic  Home  in  Utica.  Her  condition  growing  w^orse,  she  was  referred 
back  to  Dr.  DeKraft,  who  had  been  the  means  of  admitting  her  to  the  home. 
He  referred  her  to  me  at  the  Hospital  for  Deformities  and  Joint  Diseases. 

On  presenting  herself  for  examination  she  wore  a  plaster  jacket  without 
a  jury-mast.  Fig.  6  shows  location  of  knuckle,  which  we  see  in  so  many 
similar  cases.  The  disease  is  above  the  jacket  support,  hence  it  is  of  no 
mechanical  protection.  The  child  was  placed  on  a  cuirass,  and  in  five 
weeks  gained  seven  pounds.    The  photograph  was  taken  after  improvement. 

This  brings  up  the  very  important  question  of  jackets  and  braces  or 
cuirass  in  treating  children.  The  case  is  now  in  a  form  of  cuirass,  devised 
by  the  author,  made  of  gas-piping,  with  a  bar  across  the  center  (Z) ,  dropped 
two  inches,  from  which  a  metal  fork  (a-b — a-b)  covered  with  rubber  comes 
up,  upon  which  the  child  rests  (Fig.  7).  A  fork  arrangement  (c-d — c-d) 
can  be  raised  and  lowered  anteriorly  and  posteriorly,  and  by  e-f  can 
be  pressed  in  over  the  crest  of  the  ilium,  to  keep  the  pelvis  fixed,  so  that 
the  jury-mast  (h-i — h-i)  can  make  countertraction. 

Since  being  placed  on  this  cuirass  the  patient's  pain  has  disappeared. 
She  has  gained  eight  pounds,  and  is  quite  content  in  the  recumbent  position. 

To  illustrate  the  advantage  of  the  recumbent  position,  I  will  briefly  record. 

Case  2,  M.  L.,  was  sent  here  from  Tonawanda,  Pa.,  in  March,  1903,  to  con- 
sult me.  Having  no  hospital  association  to  send  charity  patients  to  at  that 
time,  I  referred  him  to  Mt.  Sinai  Hospital,  where  he  remained  two  weeks 
under  observation,  and  a  diagnosis  of  lower  dorsal  Pott's  w^as  made  by  Dr. 
H,  Koplik,  who  referred  the  case  to  the  Ruptured  and  Crippled  Hospital, 
March  18th,  where  the  child  remained  one  week  for   observation.     The 


314  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

diagnosis  of  Pott's  disease  was  confirmed,  but  treatment  was  refused,  as  the 
patient  came  from  another  State.  The  case  then  returned  to  me.  We 
placed  him  on  a  cuirass,  had  him  return  home  and  kept  in  the  open  air, 
giving  Ught  massage  to  his  disused  hmbs,  nutritious  diet,  and  had  him  return 
every  four  months.  He  remained  on  the  cuirass  nineteen  months,  then 
wore  plaster  jackets  for  two  years.  Fig.  8  shows  him  in  the  present 
condition  cured,  being  without  a  jacket  for  over  a  year. 

Case  5  represents  an  effort  to  obtain  fixation  in  the  third,  fourth,  and 
fifth  dorsal  vertebrae,  by  means  of  a  jacket  and  combination  of  metal  and 
webbing  head-band. 

This  is  impracticable  in  order  to  hold  the  head  fixed,  for  the  band  would 
be  so  tight  as  to  be  painful,  and  when  traction  is  not  added,  in  disease  of 
the  upper  dorsal  vertebra?,  there  is  no  remission  of  the  pain  in  the  intercostal 
nerves  in  this  location. 

The  patient  was  under  the  care  of  a  competent  orthopedic  specialist  for 
fourteen  months,  wearing  the  apparatus  shown  in  Fig.  4,  but  as  the 
pain  continued,  and  the  angle  of  deformity  appeared  to  increase,  she  was 
referred  to  me. 

When  a  jacket  and  jury-mast  (Fig.  9)  was  applied,  the  pain 
disappeared.  The  knuckle  is  scarcely  perceptible,  and  the  child  is  cured 
without  deformity,  showing  a  decrease  equivalent  to  one-half  inch  in  the 
knuckle  of  the  spine. 

In  place  of  a  jacket  and  jury-mast  we  may  use  a  leather  or  celluloid 
collar  in  disease  of  the  cervical  vertebra  (Fig.  10). 

I  also  wish  to  call  your  attention  to  the  most  common  error  in  the  ap- 
plication of  plaster  jackets.  When  we  fail  to  mold  the  jacket  over  the  crest 
of  the  ilium,  but  leave  the  jacket's  side  straight  to  the  crease  over  the  crest 
of  the  ilium,  we  fail  to  secure  support,  and  the  jacket  slides  up  and  down, 
excoriating  the  bony  prominence,  requiring  frequent  removal  of  the  jacket, 
and  giving  inadequate  support. 

In  conclusion  I  wish  to  state  that  unless  a  brace  rests  upon  the  bony 
pelvis  by  a  collar  across  the  crest  of  the  ilium,  or  some  similar  support,  it  is 
inefficient  and  harmful,  for  when  resting  on  the  soft  tissue,  it  slides  down 
and  adds  the  additional  weight  of  the  brace  to  the  superimposed  weight  of  the 
body  above  the  point  of  disease.  The  damage  done  to  the  vital  functions 
by  the  girding  constriction  of  the  apron  is  decidedly  detrimental  to  vital 
strength  and  resistence. 

There  is  another  serious  ill  effect  of  tightening  the  apron  on;  that  is, 
by  the  compress  produced  by  the  bar  S,  V,  Sv  SV.  We  also  have  a  com- 
pression atrophy  of  the  erector  spinse  muscles,  thus  destroying  nature's  best 
fixation  splint. 

When  disease  occurs  above  the  seventh  dorsal  vertebra,  either  the  pa- 
tient should  be  treated  in  the  recumbent  position  for  months  or  years,  or  a 
brace  or  jacket  applied  with  a  jury-mast  attached  that  will  take  off  the 
superimposed  weight  above  the  point  of  disease. 


Fio-.  5. — Author's  brace  with  collar  over  crest  of  ilium. 


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Fig.  10. — Support  for  cervical  parts,  without  constriction  of  thorax  or  abdomen. 


tJBER  DIE  NIERENTUBERKULOSE. 
Von  Dr.  G.  von  Illyes, 

Budapest. 


45  Falle  von  Nierentuberkulose,  von  welchen  36  operirt  (Nephrectomie) 
wurden.     Mortalitat,  5.56  Prozent. 

ZUSAMMENFASSUNG. 

1.  Die  Nierentuberkulose  kommt  ebenso  haufig  bei  ]\Iannern  wie  bei 
Frauen  vor. 

2.  Die  linkseitige  Nierentuberkulose  ist  ebenso  haufig  Avie  die  rechtseitige. 

3.  Die  Nierentuberkulose  entsteht  in  der  grossten  Anzahl  der  Falle  auf 
dem  Wege  der  hamatogenen  Infektion  unter  gewissen  Verhaltnissen,  jedoch 
kann  auch  eine  ascendierende  Infektion  beobachtet  werden. 

4.  Die  hiiufigste  Form  der  Nierentuberkulose  ist  diejenige,  bei  welcher 
sich  Kavernen  in  der  Niere  bilden. 

5.  Die  spontanen  Heilungen  sind  nur  scheinbare  und  nicht  dauernde. 

6.  Eine  genaue  Diagnose  im  Anfangsstadium  kann  man  nur  nach  gleich- 
seitiger  Kathetherisation  beider  Ureteren  machen. 

7.  Die  Harnscheiden  sind  nicht  verlasslich. 

8.  Die  verlasslichsten  diagnostischen  Momente  erhalt  man  durch  Bestim- 
mung  des  Gefrierpunktes  des  Urins  und  der  Verdiinnungsfahigkeit  der  Nieren. 

9.  Nach  Feststellung  der  Diagnose  ist  mogUchst  friihzeitig  die  Nephrec- 
tomie auszuf  iihren,  bevor  noch  eine  descendierende  Blasenerkrankung  entsteht. 

10.  Die  im  Urin  der  andern  Niere  auffindbaren  Eiweiss-  und  Nierenbe- 
standtheile  kontreindiciren  bei  guter  Nierenfunction  nicht  die  Entfernung 
der  laanken  Niere. 

11.  Vorhergehende  Erkrankungen  der  Blase  beschleunigen  das  Enstehen 
eines  diffusen,  tuberkulosen  Blasenkatharrs. 

12.  Eine  umschriebene  tuber kulose  Erkranloing  der  Blase  kann  nach 
Entfernung  der  kranken  Niere  spontan  heilen. 


Tuberculosis  of  the  Kidneys. — (von  Illyes.) 
The  writer  studied  45  cases  of  renal  tuberculosis,  36  of  which  came  to 
operation — nephrectomy;   mortality,  5.56  per  cent.     From  this  material  it 
can  be  seen  that: 

315 


316  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

1.  Renal  tuberculosis  is  as  frequent  among  men  as  among  women. 

2.  Renal  tuberculosis  is  just  as  frequent  on  the  left  as  on  the  right  side. 

3.  In  most  cases  renal  tuberculosis  is  due  to  hematogenous  infection; 
under  certain  conditions  an  ascending  infection  may  also  be  observed. 

4.  The  more  frequent  form  of  tuberculosis  is  that  in  which  cavities  are 
formed  in  the  lungs. 

5.  Spontaneous  recovery  is  only  apparent  and  never  permanent. 

6.  In  the  initial  stage  an  accurate  diagnosis  can  be  made  only  by  simul- 
taneous catheterization  of  both  ureters. 

7.  Urine  separators  are  untrustworthy. 

8.  The  most  trustworthy  diagnostic  points  are  obtained  by  determining 
the  freezing  point  of  the  urine  and  the  power  of  the  kidneys  to  dilute  the 
urine. 

9.  After  the  diagnosis  has  been  made,  nephrectomy  should  be  performed, 
early,  before  a  descending  cystitis  develops. 

10.  The  presence  of  albumin  and  renal  constituents  in  the  urine  of  the 
other  kidney  is  not  a  contra-indication  to  removal  of  the  diseased  kidney  if 
the  function  is  good. 

11.  Previously  existing  disease  of  the  bladder  hastens  the  development 
of  diffuse  tuberculous  cystitis. 

12.  Circumscribed  tuberculous  inflammation  of  the  bladder  may  heal 
spontaneously  after  removal  of  the  diseased  Iddney. 


Tuberculose  des  Rognons. — (von  Illyes.) 
L'auteur  a  etudie  45  cas  de  tuberculose  renale,  36  desquels  furent  operas 
(nephrectomie) ;    la  mortalite  a  6t6  de  5.56  pour  cent.     II  d^coule  des  indi- 
cations pr6cedentes  que. 

1.  La  tuberculose  renale  est  aussi  frequente  chez  les  hommes  que  chez 
les  femmes. 

2.  La  tuberculose  renale  se  produit  aussi  souvent  au  cote  gauche  qu'au 
cote  droit. 

3.  Dans  la  plupart  des  cas  la  tuberculose  renale  est  due  h  une  infection 
hematogene,  et  que  sous  certaines  conditions  une  infection  ascendante 
s'observe  aussi. 

4.  La  forme  la  plus  frequente  de  la  tuberculose  renale  est  celle  ou  des 
cavit^s  se  forment  dans  les  reins. 

5.  La  guerison  spontan^e  est  seulement  provisoire  et  n'est  jamais  per- 
manente. 

6.  Au  debut  de  la  maladie  un  diagnose  exact  ne  pent  etre  fait  que  par  la 
cath^terisation  simultanee  des  deux  ureteres. 


UEBER   DIE   NIERENTUBERKULOSE. — VON   ILLYES.  317 

7.  Les  separateurs  d' urine  ne  sont  pas  surs. 

8.  Les  renseignements  les  plus  certains  pour  un  diagnose  sont  obtenus 
en  determinant  le  point  de  congelation  de  1 'urine  et  la  capacite  des  reins 
pour  diluer  I'urine. 

9.  Apres  que  le  diagnose  a  ete  fait  nephrectomie  immediate,  avant 
qu'une  cystite  descendante  ne  se  developpe. 

10.  La  presence  d'albumine  et  d'elements  renaux  dans  I'urine  de  I'autre 
rein  n'est  pas  un  indication  contraire  a  I'enlevement  du  rein  malade. 

11.  Une  inflammation  tuberculaire  circonscrite  de  la  vessie  pent  guerir 
spontan^ment  apres  I'enlevement  du  rein  malade. 


UBER  NIERENTUBERKULOSE. 

Von  Dr.  Bela  von  Rihmer, 

Budapest. 


Seitdem  es  allgemein  bestiitigt  wurde,  dass  die  Nierentuberkulose  in  der 
Regel  von  hamatogenem  Urspriinge  ist,  die  Krankheit  in  der  iiberwiegenden 
Anzahl  der  Falle  zuerst  einseitig  auftritt,  endlich,  dass  die  Blase  nur  spater 
von  der  Niere  her  infiziert  wird,  wurden  die  Operationsindikationen  um 
vieles  erweitert.  Heute  heisst  es  im  allgemeinen,  je  friiher  zu  operieren,  um 
damit  die  Entwicklung  oder  die  Ausbreitung  der  Blasentuberkulose  zu 
verhindern. 

Verfasser  studierte  auf  Grund  von  etwa  70  Fallen  die  Symptomatologie 
und  Friihdiagnostik  der  beginnenden  Nierentuberkulose,  Ira  friihesten 
Stadium  der  Krankheitssymptome  (es  gibt  eben  eine  latente  Periode  ohne 
Symptome)  sind  diese  oft  gering  und  mogen  sie  auch  den  Verdacht  auf 
urogenitale  Tuberkulose  lenken,  ist  die  sichere  Diagnose  nur  aufzustellen, 
wenn  das  spezifische  Bakterium  im  Harne  nachweisbar  ist. 

Zusammenfassend  kann  man  als  Gesetz  betrachten,  dass  bei  jeder  rat- 
selhaft  beginnenden  Cystitis  (ohne  Gonorrhoe  oder  Katheterinfektion)  aber 
auch  bei  gonorrhoischen  Cystitiden  welche  einer  rationellen  Therapie  dauernd 
trotzen,  endlich  bei  jeder  andauernd  bestehenden  Pyurie  an  die  Moglich- 
keit  einer  Nierentuberkulose  zu  denken  ist.  Bei  jeder  Hiimaturie,  welche 
nicht  durch  Neoplasma,  Nephritiden  bedingt  wird,  weiterhin  bei  jeder  Nieren- 
kolik,  deren  Ursache  nicht  in  einem  Abflusshindernis  besteht,  sollte  man  die 
Moglichkeit  der  Tuberkulose  vor  Augen  halten. 

Verfasser  ist  der  Ansicht,  dass  die  Falle,  ausgenommen  in  welchen  Hama- 
turie  oder  Koliken  bestehen,  daher  zuerst  auf  Neoplasma  oder  Stein  unter- 
sucht  werden  sollen,  in  der  Regel  erst  nach  dem  spezifischen  Bakterium 
gesucht  werde.  Es  ist  eben  die  Aufgabe  der  Bakteriologie,  die  Aetiologie 
klarzustellen,  dann  erst  sollen  weitere  Untersuchungen  (Cystoskopie, 
Ureterenkatheterismus),  die  Lokalisation  des  Uebels  zu  machen,  unter- 
nommen  werden. 

Betreffs  des  Nachweises  des  spezifischen  Bakteriums  hat  Verfasser  im 
pathologisch-anatomischen  Institute  des  Herrn  Hofrates  Prof.  Pertik  in 
mehreren  Richtungen  Versuche  gemacht. 

Bekanntlich  geschieht  der  Nachweis  der  Bazillen  durch  Farbung  oder 

318 


iJBER   NIERENTUBERKULOSE. — VOX   RIHMER.  319 

Ausziichtiing,  endlich  durch  Tierexperimente.  Aiif  Nahrboden  misslingt 
die  Ausziichtung  wegen  Mischinf elction  gar  zu  oft ;  doch  gelang  uns  dies  mit 
Doz.  Krompecher  in  4  meiner  instrumentell  noch  nicht  behandelten  Falle, 
aus  dem  steril  entnommenen  Urin  aiif  4%  Glycerin-Kartoffel.  Es  ware 
wiinschenswert,  wenn  die  Aerzte  in  Fallen  ratselhaft  beginnender  Cystitis, 
anstatt  typische  Behandlung  einziifiihren,  erst  immer  diese  Untersuchung 
machen  mochten.  Bleibt  die  4%  Glycerin-Kartoffel  tagelang  steril,  dann 
fehlen  die  gewohnlichen  Cystitiserreger  im  Eiter,  der  Fall  ist  wahrscheinlich 
Tuberkulose. 

Beziiglich  des  Nachweises  der  Bazillen  mit  Farbungsmethoden  sind  die 
Schwierigkeiten  geniigend  bekannt.  Der  Nachweis  gelang  nur  in  etwa  50% 
der  Falle.  Dabei,  wie  sich  es  spater  zeigte,  haben  diese  spezifischen  Farbungs- 
methoden zu  Irrtiimern  gefiihrt.  So  wurden  in  der  Litteratur  Falle  publi- 
ziert  (Konig,  Lonmeau,  Milahner),  in  welchen  auf  Grund  dieser  Farbungen 
im  Harne  Koch's  Bazillen  nachgewiesen  wurden  und  bei  der  histologischen 
Untersuchung  der  nephrektomisierten  Niere  andere  Erkrankung  und  keine 
Tuberkulose  konstatiert  wurde.  Die  Ursache  des  Irrtums  ist,  dass  im 
Smegma  der  Genitalien  Bazillen  zu  finden  sind,  welche  ebenso  saurefrei  sind 
wie  der  Koch'sche  Bazillus.  Spater  hat  man  es  nachgewiesen,  dass  diese 
nicht  pathogenen,  saurefesten  Bazillen  sozusagen  ubiquitare  Organismen 
sind,  und  man  bestrebte  sich  dann,  neuere  Differenzial-Farbungen  aufzu- 
finden.  Verfasser  hat  nach  dreierlei  Richtungen  hin  Untersuchungen  aus- 
gef  iihrt : 

1.  Fraglich  war,  ob  saurefeste  Bazillen  wirklich  nur  mit  dem  Smegma 
in  den  Harn  gelangen,  oder  aber  konnen  solche  im  Blasenurin  vorhanden  sein? 
Verfasser  hat  in  der  obersten  Schichte  der  mit  ausgegliihtem  Messer  abge- 
schabten  Blasen-  und  Ureterenschleimhaut  von  15  absolut  tul^erkulosefreien 
Leichen  einmal  reichlich,  nach  Gabbet  sich  farbende,  kurze,  dicke  Bazillen 
gefunden, 

2.  Da  es  angenommen  wurde,  dass  die  saurefesten  Bazillen  des  Smegma 
dem  Koch'schen  Bazillus  zwar  gleich  saurefrei  sind,  jedoch  aber  minder 
alkoholfest,  wurden  zur  Differenzierung  der  beiden  Arten  neuere  Farbungs- 
methoden angewendet.  Von  den  neuerdings  gclobten  wurden  die  von  Hou- 
sell  und  die  von  Forsal  empfohlenen  nachgeprtift.  Nach  H.  entfiirbt  man  mit 
3%  Salzsaurealkohol  10  Minuten  lang,  nach  F.  mit  25%  Salpetersaure  3 
Minuten  und  dann  mit  50%  Azetonall^ohol  wieder  3  Minuten  lang.  Verfasser 
konnte  in  den  nach  diesen  Methoden  verfertigten  Praparaten  im  Smegma 
niemals  rotfarbig  gebliebene  Bazillen  finden.  Es  muss  aber  bemerkt  werden, 
dass  hie  und  da  nach  Forsal  auch  der  Koch'sche  Bazillus  entfiirbt  warde. 

3.  Drittens  farbte  er  nach  H.'s  und  F.'s  Methode  solche  saurefeste  Bazil- 
len, welche  nicht  eben  aus  dem  Smegma  der  Genitalien,  sondern  von  anderen 
Teilen  der  Korperoberflache,  oder  dem  Innem  des  menschlichen  Organismus 


320  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

entstammend,    sich   dem    Urin   wohl  beimengen  konnten.     Diese  waren: 

(a)  der  Moller'sche    Smegmabazillus,    geziichtet   aus    dem   Nabelsmegma, 

(b)  Morpmann's  Bazillus,  geziichtet  aus  dem  Harne,  (c)  ein  von  Krompecher 
aus  .einem  geschlossenem  Pleuraexudate  geziichteter  siiurefester  Bazillus, 
der  bei  Zimmertemperatur  reichlich  gedieh,  und  fiir  das  Tier  uicht  pathogen 
war.  Dieser  letztere  bheb  nach  den  beiden  Farbungsmethoden  ebenso 
gefarbt,  \vie  der  Koch'sche  Bazillus;  die  beiden  ersteren  dekolorierten  sich 
nach  Forsal,  blieben  aber  nach  Housell  gefarbt. 

Aus  diesen  Versuchen  resultiert,  dass  wenn  auch  selten  aber  immerhin 
auch  moglicher  Weise  aus  der  Blase  saurefeste  Bazillen  sich  dem  Harne 
beimengen  konnen  und  dass  auch  nach  den  neuesten  beliebten  Tinlctions- 
methoden  solche  saurefeste  Bazillen  gefarbt  bleiben,  welche  sich  dem  Harne 
beimengen  konnen.  Aus  diesem  folgt  aber,  dass  in  alien  jenen  tuber- 
kuloseverdachtigen  Fallen  in  welchen  das  klinische  Bild  ein  solch'  unklares 
ist,  dass  zur  Aufstellung  der  Diagnose  der  jeden  Zweifel  ausschliessende 
Nachweis  des  Bazillus  erforderlich  ist,  als  einzig  sichere  Methode  die  Tier- 
impfung  angewendet  werden  muss.  Dies  sind  eben  die  noch  auf  die  Niere 
beschrankten,  ganz  beginnenden  Falle.  Zur  Schnelldiagnose  ware  die 
Tuberkulinreaktion  anzuwenden,  welche  dem  Verfasser  in  4  Fallen  gute 
Dienste  leistete.  Die  Diagnose  einer  Nierentuberkulose  kann  man  aber  mit 
der  Reaktion  nur  dann  sicher  aufstellen,  wenn  wir  neben  der  allgemeinen 
Reaktion  (Fieber)  auch  Herdreaktion  bekommen  (Nierenschmerzen,  Blutung, 
Harnschmerz).  Ist  die  Aetiologie  der  Erkrankung  sicher  gestellt,  so  folgt 
die  Lokalisation  derselben;  da  die  Palpation  oft  keine  Aufklarung  gibt,  auch 
manchmal  irre  fiihren  kann  (kollateraler  Schmerz),  miissen  wir  das  Cystoskop 
anwenden,  die  intravesikale  Trennung  mit  dem  Ureterenkatheterismus 
ausflihren.  Ueber  den  Wert  der  einzelnen  Verfahren  mochte  Verfasser  nur 
ganz  kurz  bemerken,  dass  er  die  einfache  Cystoskopie  mit  Besichtigung  der 
Ureterenoffnungen  (Meatoskopie)  fur  ein  unvollkommenes  Verfahren  halt, 
welches  irre  fiihren  kann.  Es  war  in  einem  Falle  z.  B.  doppelte  Nierentuber- 
kulose mit  einseitigen  Blasenveranderungen  verbunden  etc. 

Vollige  Sicherheit  gibt  nur  der  beiderseitige  Ureterenkatheterismus, 
mit  welchem  man  sich  iiber  den  Zustand  jeder  einzelnen  Niere  orientieren 
kann.  Der  getrennt  aufgefangene  Urin  beider  Seiten  wird  zuerst  den  ge- 
wohnlichen,  chemisch-mikroskopischen  Untersuchungen  und  dann  den 
funktionellen  Prufungen  unterworfen.  Er  ist  ein  Anhanger  der  Kolpo- 
skopie. 

Was  die  Indikationen  fiir  die  Operationen  anbetrifft,  sollte  nach  Ver- 
fassers  Meinung,  ausgenommen  die  Falle,  in  welchen  multiple  Tuberkulose- 
herde  vorhanden  sind,  jede  sicher  einseitig  beginnende  Nierentuberkulose 
operiert  werden. 

a.  Die  funktionellen  Untersuchungen,  ergeben  eine  erhebliche  Funlctions- 


iJBER   NIERENTUBERKULOSE. — VON   RIHMER.  321 

stomng  der  erkrankten  Niere  gegeniiber  der  restierenden  well  in  diesen 
Fallen  trotz  des  anscheinend  friihen  Stadiums  grosserer  Parenchymverlust 
und  eine  grossere  Zerstorung  bestehen. 

b.  Wenn  audi  die  Funktionen  der  beiden  Nieren  nicht  erheblich  differ- 
ieren,  aber  das  Uebel  in  der  Blase  um  die  Ureterenoffnung  zu  konstatieren  ist. 

c.  Wenn  die  subjektiven  Beschwerden  gross  sind  und  dadurch  das  allge- 
meine  Befinden  leidet.  Wenn  aber  bei  einseitiger  Bazillurie  mit  geringer 
oder  fehlender  Pyurie  und  Albuminurie  die  funlctionelle  Priifung  (bei  beider- 
seitigen  guten  funktionellen  Werten)  keinen  Unterschied  ergibt,  soUte  der 
Fall  unter  stetiger  Kontrolle  erst  medizinisch  behandelt  werden. 


Tuberculosis  of  the  Kidney. — (von  Rihmer.) 
The  author  has  studied  the  symptomatology  and  early  diagnosis  of 
beginning  renal  tuberculosis  in  about  20  cases.  In  the  earlier  stages  of  the 
disease  the  symptoms  are  often  slight;  in  fact  there  is  a  latent  period  with- 
out symptoms;  but  even  when  the  symptoms  arouse  a  suspicion  of  uro- 
genital tuberculosis,  the  diagnosis  can  be  rendered  certain  only  by  finding 
the  specific  organism  in  the  urine. 

Animal  inoculation  is  the  only  infallible  method  of  demonstrating  the 
bacillus.  Attempts  at  cultivating  the  bacillus  are  unsuccessful  on  account 
of  mixed  infection;  and  the  difficulties  of  staining  the  bacillus  are  well 
known.  In  collaboration  with  Dr.  Krompecher,  the  writer  succeeded  in 
cultivating  the  tubercle  bacillus  on  4  per  cent,  glycerin-potato  in  4  of  his 
cases  that  had  not  been  treated  surgically.  The  urine  was  obtained  under 
aseptic  precautions.  In  spite  of  the  admitted  difficulties  of  cultivating  the 
bacillus  the  method  deserves  more  attention  than  it  has  received  in  the  past, 
for  if  a  4  per  cent,  glycerin-potato  tube  remains  sterile  for  several  days,  it 
shows  that  the  usual  causes  of  cystitis  are  absent,  and  the  case  is  probably 
tuberculous.  The  author  gives  a  resume  of  his  views  with  regard  to  the 
early  diagnosis  and  treatment  of  renal  tuberculosis.  Whenever  a  cystitis 
begins  in  some  obscure  manner  (without  gonorrhea  or  catheter  infection), 
and  whenever  a  gonorrheal  cystitis  proves  refractory  to  rational  treatment, 
finally  in  every  case  of  persistent  pyuria,  the  possibility  of  renal  tuberculosis 
should  he  borne  in  mind.  In  every  case  of  hematuria  not  due  to  neoplasms 
or  a  nephritis,  and  in  cases  of  renal  colic  not  explained  by  obstruction,  re- 
member the  possibility  of  tuberculosis  should  not  be  forgotten. 

With  the  exception  of  cases  in  which  multiple  tuberculous  foci  are  present, 
every  case  of  beginning  tuberculosis  in  which  the  diagnosis  is  positive  should 
be  treated  by  operation  if:  (a)  the  functional  examination  shows  that  the 
functional  power  of  the  diseased  kidney  is  considerably  diminished  and  (6) 

VOL.  II — 11 


322  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

when  the  function  of  both  kidneys  is  not  appreciably  diminished,  if  the 
cystitis  has  passed  beyond  the  opening  of  the  ureters;  (c)  when  subjective 
symptoms  are  severe  and  sufficient  to  impair  the  general  health. 


Tuberculosis  de  los  Rinones. — (von  Rihmer.) 
El  autor  ha  estudiado  tuberculosis  renal,  al  principio  de  la  afeccion,  en 
cerca  de  veinte  casos.  Al  principio  de  la  enfermedad  los  slntomas  son 
muchas  veces  ligeros,  y  aun  existe  un  periodo  latente  desprovisto  de  sinto- 
mas;  mas  aun  cuando  los  sintomas  son  suficientemente  marcados  para 
dar  sospechas  de  la  afeccion  tuberculosa  de  los  organos  genito-urinales,  el 
diagnostico  es  confirmado  solamente  cuando  el  bacilo  de  la  tuberculosis  se 
encuentra  en  la  orina. 

La  inoculacion  en  los  animales  es  el  metodo  mas  segura  para  demostrar 
la  presencia  del  bacilo.  El  cultivo  del  bacilo  por  lo  general  tiene  poco  exito 
debido  a  la  infeccion  mixta,  y  bien  sabidas  son  las  dificultades  que  se  encuen- 
tran  en  la  coloracion  del  bacilo.  En  colaboracion  con  el  Dr.  Krompecher,  el 
autor  ha  logrado  cultivar  el  bacilo  de  la  tuberculosis  en  la  patata  glicerinada 
al  4%  en  cuatro  de  sus  casos  que  no  habian  recivido  el  tratamiento  quirurgico. 
La  orina  fue  colectada  bajo  condicionas  asepticas.  En  vista  de  las  dificultades 
que  presenta  el  cultivo  del  bacilo  de  la  tuberculosis,  este  metodo  merece 
mayor  atencion  que  la  que  hasta  el  presente  se  le  ha  dada,  puesto  que  si  los 
tubos  de  patata  glicerinada  al  4%  permanecen  esteriles  por  algunos  dias,  esto 
demuestra  quelas  causas  usuales  de  cistitis  son  absentes  y  que  la  causa  por 
lo  tanto  es  de  origen  tuberculoso.  Ademas  de  exponer  los  resultados  de  sus 
experimentos  en  el  metodo  para  demostrar  el  bacilo  dela  tuberculosis,  el 
autor  da  un  resumen  de  su  parecer  sobre  el  diagnostico  prematuro  y  el  trata- 
miento de  la  tuberculosis  renal.  En  todos  los  casos  en  que  la  cistitis  empieza 
de  un  modo  oscuro  (sin  gonorrea  li  otra  infeccion),  6  cuando  una  cistitis  se 
muestra  refractaria  al  tratamiento  racional,  finalmente  en  cada  caso  de  una 
piuria  persistente,  las  posibilidades  de  la  tuberculosis  renal  deberan  tenerse 
presentes.  En  cada  caso  de  hematuria,  que  no  sea  debido  a  un  neoplasma 
6  a  una  nefritis,  y  en  los  casos  del  colico  renal  que  no  sea  debido  a  una 
obstruccion,  las  posibiUdades  de  la  tuberculosis  no  deben  olvidarse. 

El  autor  cree  que  exceptuando  los  casos  en  los  cuales  existen  varios  focos 
de  tuberculosis,  cada  caso  de  tuberculosis  al  principio  de  la  infeccion  debera 
tratarse  por  medio  de  una  operacion  bajo  las  condiciones  siguientes:  (a)  si  el 
examen  functional  demuestra  que  la  f uncion  del  rifion  afectado  ha  disminuido 
conciderablemente;  (6),  cuando  la  f  uncion  de  ambos  rinones  no  ha  disminuido 
apreciablemente,  cuando  la  cistitus  no  ha  pasado  mas  alia  de  la  abertura  de 
los  ureteres;  (c)  cuando  los  sintomas  subjectivos  son  severos  y  suficientesj 
para  causar  un  desconcierto  de  la  salud  general. 


A   STUDY   ON  EXPERIMENTAL  TUBERCULOSIS   OF 

THE  TESTICLE. 

By  Ch.  Esmonet, 

Of  Chatel-Guyon,  Chief  of  the  Civiale  Laboratory  (Lariboisifere,  Paria). 


We  have  caused  the  tubercuHzation  of  the  testicle  by  puncture  and  by 
injection  into  the  vas  deferens,  into  the  general  venous  system,  and  into  the 
spermatic  artery. 

1.  Tuberculization  of  the  Testicle  by  Puncture. 

Exp.  I. — Dog  No.  13,  weighing  12  kilograms,  in  the  same  time  as  an  in- 
jection of  bouillon  of  human  tuberculosis  in  the  right  spermatic  artery,  has 
received  in  the  left  testicle  1  c.c.  of  the  same  bouillon  by  multiple  punctures 
(March  25th). 

March  28th :  Both  testicles  are  hard  and  painful. 

April  2d:  Both  testicles  are  taken  away. 

The  state  of  the  right  testicle  will  be  described  later. 

The  left  testicle  presents  several  spots  about  the  size  of  the  head  of  a  pin. 
When  examined  with  a  microscope,  those  spots  appear  to  correspond  with 
foci  of  tuberculous  infiltration,  and  on  their  level  one  finds  seminiparous 
tubes  blended  together.  On  the  periphery  of  the  infiltration  may  be  found 
all  the  intermediate  stages  of  spermatic  catarrh.  Sometimes  the  tubes  pre- 
sent a  total  desquamation  of  the  epithelium.  The  nuclei  cannot  be  stained; 
spermatozoa  can  scarcely  be  recognized  by  their  feebly  taking  hematoxylin. 
In  places  the  seminal  epithelium  looks  normal,  has  its  ordinary  reactions 
with  stains,  and  allows  the  distinction  of  numerous  spermatozoids. 

Exp.  II. — Dog  No.  41,  weighing  lU  kilograms.  April  1st:  Multiple 
punctures  in  the  left  testicle  with  1  c.c.  of  emulsion  of  bacilli  from  tuber- 
culous mammitis  of  a  cow.     The  right  testicle  is  left  untouched. 

April  19th:  Nearly  dying  animal  killed  with  cyanid  of  potassium.  The 
right  testicle  is  normal  by  the  naked  eye.  With  a  microscope,  one  may  see 
epithelium  in  the  state  of  pre-spermatogenesis. 

The  left  testicle  presents  small  reddish  points  scattered  about  in  the  paren- 
chyma.    The  volume  of  the  testicle  does  not  exceed  that  of  the  other  one. 

By  microscopical  examination  one  finds  foci  of  tuberculous  infiltration, 
pretty  well  limited,  not  yet  necrotic,  and  characterized  by  an  extreme  abun- 
dance of  polynuclears,  many  of  which  seem  to  be  in  a  state  of  karyolysis, 
showing  clearly,  by  the  acute  coloration  of  their  nuclei  on  the  ground  of  the 
intertubular  tissue;  while  most  of  the  elements  of  the  connective  tissue  are 
scarcely  colored,  and  seem  to  be  about  to  disappear.  Koch's  bacilli  are 
abundant. 

323 


324  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

The  seminiparous  tubes  that  are  in  contact  with  tuberculous  nodules 
present  an  epithelium  desquamated  in  a  lump,  where  nothing  clear  may  be 
distinguished.  The  tubes  which  are  distant  from  the  tuberculous  foci  pre- 
sent a  normal  appearance.  Their  epithelium  is  in  a  state  of  pre-spermato- 
genesis. 

The  other  organs  are  somewhat  discolored.  The  liver  is  yellowish,  fat, 
very  soft.  Histological  examination  shows  numerous  tuberculous  granula- 
tions in  a  beginning  stage.  Glycogen  has  completely  disappeared  from  the 
liver,  except  about  the  granulations. 

The  parenchj^ma  of  the  kidney  presents  granular  and  fatty  degeneration, 
easily  seen  on  a  level  with  the  tubuli  contorti.  Small  but  numerous  hemor- 
rhages are  scattered  everywhere. 

Dog  No.  22  received  by  multiple  punctures  about  1  c.c.  of  bouillon 
emulsion  of  human  bacilli  in  the  right  testicle,  which  became  congested, 
hemorrhagic  at  all  the  points  of  puncture.  The  epididymis  seemed  much 
injured. 

In  short,  injections  in  the  parenchyma  give  much  better  results  than  in- 
jection by  the  vas  deferens. 

2.  Injections  of  Koch's  Bacilli  in  the  General  Venous  Circulation. 

Exp.  III. — Dog  No.  3,  weighing  11.1  kilograms. 

Jan.  27th:  Venous  injection  of  human  tuberculosis:  3  c.c.  of  bouillon 
emulsion.  Repeated  traumatisms  of  the  right  testicle.  The  animal  pre- 
senting no  change,  subcutaneous  injection  of  tuberculin  was  made  on  March 
4th.     Weight  13.3  kilograms. 

March  28th:  Good  health.     Weight  14.2  kilograms. 

April  1st:  Venous  injection  of  bacilli  from  tuberculous  mammitis  of  a 
cow — ^3  c.c. 

June  6th:  Weight  11.5  kilograms.     Emaciation.     Cachexia. 

The  animal  was  killed  on  April  8th.  Generalized  tuberculosis.  The 
testicles  are  normal.  Numerous  spermatozoa  and  glycogen  are  found  in 
the  testicles. 

Former  traumatisms  seem  to  have  had  in  this  case  no  action  on  the  local- 
ization of  tuberculosis,  the  right  testicle  being  untouched.  The  action  of 
bovine  tuberculosis  seems  to  have  been  more  striking  than  that  of  the  human 
bacilli,  all  reserves  made  about  the  predisposing  part  played  in  tliis  case  by 
the  former  injections  of  human  tuberculosis. 

Exp.  IV. — Dog  No.  2,  weighing  8  kilograms. 

Oct.  29th:  Injection  of  tuberculosis  from  bovine  mammitis  in  the  vein 
of  the  ear,  3  c.c.  of  bouillon  emulsion. 

Nov.  25th:  Sacrificed  while  very  sick  (twenty-seventh  day).  Right 
testicle,  in  inguinal  ectopia.  Left  testicle,  normal  aspect,  color,  consistency. 
By  microscopical  examination  no  lesion  seen  in  the  testicle,  right  or  left. 
The  ectopic  testicle  has  no  differentiated  cells.  The  left  one  is  full  of  sper- 
matozoa. 

The  animal  has  died  from  generalized  granulia,  histologically  recognized 
in  the  liver,  spleen,  lungs,  kidneys. 


EXPERIMENTAL  TUBERCULOSIS   OF   TESTICLE. — ESMONET.  325 

Exp.  V. — Dog  No.  50.  Intravenous  injection  of  human  tuberculosis 
thirty-three  days  before.  Shght  beginning  of  granulia  in  the  liver  and  lungs. 
Some  granulations  under  the  pleura.  Nothing  in  the  testicle.  Normal 
spermatogenesis. 

Exp.  VI. — Dog  No.  5.  Intravenous  injection  of  human  tuberculosis 
sixty  days  before.  Killed.  Generalized  granulia.  No  appreciable  lesion 
in  the  testicle.     Normal  spermatogenesis. 

Exp.  VII. — Dog  No.  4.     Weight  15  kilograms. 

July  15th:  Injection  of  human  tuberculosis  by  the  venous  way;  3  c.c. 
Killed  on  the  sixtieth  day  in  a  state  of  cachexia.  Weight  11.5  kilograms. 
Generalized  granulia,  histologically  verified.  The  testicles  are  normal  from 
a  macroscopical  point  of  view.  With  the  microscope  no  alteration  can  be 
seen  in  the  albuginea  or  in  the  connective  tissue.  No  vaso-dilatation,  no 
hemorrhage,  no  formation  resembling  a  nodule  in  any  way. 

The  wall  of  the  seminiparous  tubes  is  normal.  In  the  epithelium  ordinary 
layers  of  spermatogonias,  spermatoc}i:es,  spermatoids,  and  spermatozoa. 
But  no  tube  is  normal  in  regard  with  the  aspect  of  the  seminal  cells.  In- 
stead of  being  individualized,  they  agglomerate,  especially  on  a  level  mth 
the  la3^ers  of  spermatoc}i;es.  Besides  their  coloring  reactions,  the  mor- 
phology of  their  nuclei  remains  normal.  But  instead  of  finding  one  nucleus 
for  each  cell,  one  may  see  evei'j^where,  side  by  side,  protoplasmic  blocks  that 
represent  the  union  of  eight  or  ten  spermatocytic  cells.  The  nuclei  remain 
very  clear,  well  colored,  in  these  protoplasmic  masses,  each  of  which  is  clearly 
rounded,  well  limited  outwardly,  and  presents  neither  on  the  edge  nor  in  the 
interior  the  least  mark  of  constriction  or  of  a  beginning  division. 

Besides  these  protoplasmic  groups,  epithelial  cells  may  be  found  with 
normal  characters.  Moreover,  the  varieties  are  related  to  the  number  of 
nuclei  from  the  protoplasmic  plates  with  many  nuclei  to  the  seminal  cell  in 
one  of  its  normal  stages.  No  focus  of  caseation  exists  on  a  level  with  those 
formations.  Everything  equally  takes  stain.  Multiple  trials  of  coloration 
of  Koch's  bacilli  are  fruitless.     Spermatozoa  are  abundant. 

We  think  we  are  here  in  presence  of  a  case  of  spermatogenesis  with  an 
abnormal  evolution,  on  account  of  the  tuberculosis  and  of  the  tuberculous 
toxins  circulating  in  the  blood  and  causing  deviation  of  the  genital  function 
from  a  morphological  point  of  view.  This  is  the  only  case  of  this  kind  we 
have  seen.  In  fact,  we  have  reproduced,  by  injection  of  infectious  agents, 
of  tuberculosis  especially,  in  the  spermatic  arteries,  catarrhal  lesions  of  the 
seminiparous  tubes,  causing  lesions  in  the  epithelium  looking,  at  first  sight, 
like  the  pseudo  giant-cells  we  met  with  in  the  above  case.  But  it  is  easy  to 
ascertain  that  in  those  cases  of  catarrh  there  are  alterations  of  the  protoplasm 
unequally  or  not  at  all  colored.  The  nuclei  seem  to  conglomerate.  But 
their  chromatic  filaments  dilate  before  they  disaggregate,  till  they  reach  a 
volume  three  or  four  times  greater  than  normal.  They  are  colored  in- 
tensely. One  may  see  them  segmenting,  reducing  to  small  balls,  resembling 
the  changes  in  karyolysis.    There  is  nothing  comparable  here. 

In  short,  the  trials  of  tuberculization  of  the  testicle  by  the  venous  channels 
have  not  been  successful  in  the  dog.  The  only  lesion  we  have  been  able  to 
obtain,  and  that  in  only  one  case,  is  an  abnormal  evolution  of  spermatogenesis. 

We  believe  it  possible  to  cause  testicular  tuberculosis  by  the  general 


326  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

venous  circulation  in  the  dog;  but  this  process  is  uncertain,  and  we  prefer 
the  injection  by  the  way  of  the  spermatic  artery.  It  seems  possible  that 
experimental  tuberculosis  of  the  testicle  in  the  dog  may  be  obtained  in  con- 
ditions analogous  to  those  one  must  realize  to  determine  the  same  lesion  in 
guinea-pigs. 

In  the  guinea-pig,  when  tuberculization  is  rapid,  tuberculous  foci,  ma- 
croscopically  perceptible,  are  seldom  found  in  the  testicle.  When  tuber- 
culization is  slow,  one  may  see  the  testicle  enlarging,  presenting  caseous 
nodules  from  the  size  of  a  pin's  head  to  that  of  a  hemp-seed;  sometimes  the 
whole  testicle  becomes  a  caseous  mass. 

Three  guinea-pigs,  inoculated  in  the  pleura  on  March  12,  1902,  with  half 
a  cubic  centimeter  of  bouillon  emulsion  of  Koch's  bacilli,  died  nine  or  ten 
months  afterward.  All  of  them  presented  generalized  tuberculosis;  two  of 
them  had  very  deep  tuberculization  of  the  testicle;  the  third  one  some  granu- 
lations not  veiy  far  advanced. 

3.  Injections  of  Koch's  Bacilli  in  the  Vas  Deferens. 

Exp.  VIII. — In  a  first  trial  we  injected  into  the  deferent  canal  an  emulsion 
containing  many  Koch's  bacilli.  A  temporary  ligature  around  the  needle 
caused  the  emulsion  to  go  high  in  the  spermatic  vessels.  Five  minutes  after 
the  injection  the  ligature  was  removed,  the  needle  taken  away,  and  the 
wound  closed. 

The  animal  presented  no  symptom,  either  local  or  general,  during  the 
days  or  weeks  that  followed.  Two  months  afterward,  ablation  of  the  tes- 
ticles showed  that  the  two  glands  were  absolutely  uninjured,  the  epithelium 
normal,  with  numerous  spermatozoa.  Nothing  in  the  interstitial  tissue  or 
epicUdymis  or  deferent  canal.  Bladder  and  kidneys  were  normal.  The 
lumbar  glands  were  histologically  unchanged.  It  seems  that  Koch's  bacilli 
had  been  little  by  little  carried  toward  the  bladder  by  the  sperm,  and  after- 
ward evacuated  with  the  urine,  without  causing  any  tuberculous  lesion. 

We  have  repeated  this  experiment,  always  with  a  ligature  on  the  deferent 
canal,  but  at  the  same  time  we  injured  the  spermatic  vessels  or  the  testicle. 
We  made  the  Ugature  of  the  spermatic  artery  so  as  to  facilitate  the  infection 
of  the  gland,  by  causing,  at  least  for  a  time,  epithelial  alterations  that  should 
give  more  easy  access  of  the  bacilli  to  the  interstitial  tissue. 

Moreover,  we  have  injured  the  testicle  and  the  deferent  canal. 

Exp.  IX. — Dog  No.  15,  weight  21  kilograms. 

Nov.  19th:  Right  testicle:  Ligature  of  the  spermatic  artery.  Injection 
of  15  drops  of  emulsion  from  bovine  mammitis  into  the  vas  deferens.  Left 
testicle:  Injection  of  tuberculosis  from  mammitis  in  the  vas  deferens,  after 
having  excoriated  it  with  the  needle  and  after  having  injured  the  testicle. 
No  reaction  in  the  epididymis  and  testicles  on  the  following  days. 

December  20th:  Both  testicles  seem  to  have  lost  volume,  especially  the 
right  one,  harder  and  more  embossed. 


EXPERIMENTAL  TUBERCULOSIS    OF   TESTICLE. — ESMONET.  327 

Jan.  12th  (fifty-fourth  day):  Ablation  of  both  testicles.  Right  testicle: 
It  weighs  7  grs.,  is  atrophied  and  hard;  presents  in  its  center  a  whitish, 
indurated,  not  caseous  block.  Left  testicle:  It  weighs  14  grs.  Its  appearance 
is  wliitish  and  it  is  very  hard. 

On  the  right  side,  the  testicle  is  represented  by  a  block  of  embryonal  in- 
filtration, showing  no  outline  of  seminiparous  tubes.  Numerous  bacilli  are 
found.  The  atrophied  testicle  is  inclosed  by  the  epididymis,  surrounding 
it  almost  completely.  The  appearance  of  the  testicle  is  normal  in  most 
places.     In  other  places  the  interstitial  tissue  is  deeply  infiltrated. 

On  the  left  side,  a  large  block  of  embryonal  infiltration,  with  numerous 
bacilli,  is  found  in  contact  with  the  canals.  The  seminiparous  tubes  have 
desquamated.  No  signs  of  spermatogenesis  are  found.  A  profuse  network 
shows  a  recent  seminal  catarrh  with  the  formation  of  large  catarrhal  cells. 
These  lesions  exist  only  where  the  interstitial  tissue  is  infiltrated.  Where 
there  is  no  infiltration,  the  seminal  epithelium  has  its  normal  characters, 
its  numerous  spermatozoa.  One  may  find  fat  remaining  in  the  interstitial 
spaces,  even  in  a  tuberculous  focus.  The  seminiparous  tubes  are  all  wholly 
free  from.  fat. 

The  animal  is  killed  two  months  afterward.  There  is  no  evidence  of 
tuberculous  foci. 

In  the  following  experiment  we  did  not  injure  the  excretory  and  secretory 
spermatic  canals,  but  we  injected  the  tuberculous  culture  into  the  deferent 
canals  after  having  ligatured  it  around  the  needle. 

Exp.  X. — Dog  No.  16,  big  dog,  very  young,  weighing  17  kilograms. 
Both  testicles  are  very  small. 

January  17th:  Ligature  of  both  deferent  canals  and  injection  of  human 
tuberculosis.     No  inflammatory  reaction. 

February  9th :  The  testicles  are  veiy  hard. 

The  dog  was  killed  on  the  thirtieth  day  after  ligature.  Nothing  found  in 
the  organs.  The  liver  is  somewhat  discolored.  It  is  fat,  but  contains  no 
tubercle.  The  right  testicle  weighs  10  grs.;  the  left  one  11  grs.  The  epidid- 
ymis on  both  sides  is  hard.  The  canals  are  transparent  and  dilated.  No 
tuberculous  nodule  macroscopically  appreciable.  The  testicle  seems  to  be 
histologically  normal,  but  no  spermatozoa  are  found.  Both  testicles  are 
much  glycogenated. 

The  absence  of  spermatozoa  seems  to  be  due  to  the  age  of  the  animal. 
It  is  a  testicle  in  a  state  of  pre-spermatogenesis,  where  the  seminal  epithelial 
cells  are  alike. 

In  this  case,  notwithstanding  the  great  quantity  of  injected  bacilli,  the 
result  has  been  nil,  at  least  for  the  testicular  parenchyma.  Thirty  days  after 
the  puncture  the  deferent  and  epididymal  canals  were  still  distended  by  the 
injection,  and  colorable  Koch's  bacilli  were  found  in  it.  But  we  could  scarcely 
detect  a  beginning  infiltration  in  the  connective  tissue  near  to  the  epididymal 
canal.  Epithelium  of  the  canaliculi  seems  to  have  retained  its  integrity. 
One  may  see  how  uncertain  is  the  method  of  tuberculization  by  way  of  the 
deferens.  Notwithstanding  the  retention  of  Koch's  bacilli,  there  was  little 
or  no  infection  of  the  adjacent  tissues. 


328  sixth  international  congress  on  tuberculosis. 

4.  Injections  of  Koch's  Bacilli  in  the  Spermatic  Artery. 

The  injections  of  tuberculous  bacilli  in  the  dog's  spermatic  artery  were 
made  with  human  bacilli  or  bovine  baciUi  of  tuberculous  mammitis.  The 
testicles  were  taken  away  at  intei'vals  varying  from  twenty-four  hours  to 
sixty-eight  days.  In  nine  cases  we  obtained  a  more  or  less  extensive  tuber- 
culous infiltration  A\ith  concomitant  tubular  lesions.  In  one  case  the  testicle 
was  the  seat  of  advanced  caseation. 

In  four  testicles  we  were  able  to  discover  no  lesions.  The  testicles  of 
the  first  dog  were  examined  twenty-four  hours  after  the  injection,  so  we  could 
not  expect  to  find  anything.  In  the  second  dog  (No.  9)  the  same  injection 
made  in  the  spermatic  artery,  right  or  left,  has  given  but  a  negative  result 
for  the  left  testicle  on  the  twenty-fifth  day,  and  a  veiy  light  result  for  the 
right  testicle  on  the  forty-fifth  day. 

Exp.  XL — Dog  No.  13.     Weight  12.5  kilograms. 

March  25th:  Injection  in  the  right  spermatic  artery  of  1.5  c.c.  of  bouillon 
emulsion  of  human  bacilli.  On  the  left  side  the  testicle  was  repeatedly 
punctured. 

March  28th:  Weight  12  kilograms.     Both  testicles  are  hard  and  painful. 

April  2d  (seventh  day  after  injection) :  Both  testicles  are  red  and  tume- 
fied. The  right  testicle  is  uniformly  congested,  with  whitish  patches, 
showing  distinctly  on  the  red  background. 

The  left  one  presents  lesions  already  described,  in  connection  with  ex- 
perimental tuberculosis  of  the  testicle  by  puncture  of  the  parenchyma. 

Exp.  XII. — Dog  No.  8,  weighing  23.5  kilograms. 

March  25th:  Injection  in  the  left  spermatic  artery  of  1.5  c.c.  of  bouillon 
emulsion  tuberculous  mammitis  (bovine). 

March  28th:  Weight,  22  kilograms.     Testicles  large  and  painful. 

April  1st:  The  testicle  keeps  enlarged,  but  is  no  more  painful. 

April  12th  (seventeenth  day  after  injection):  The  left  testicle  is  taken 
away.  It  is  large  and  heavy.  It  presents  a  very  striking  asymmetry  on  one 
side.  It  is  very  much  congested,  with  yellowish  blots  showing  clearly  on 
the  red  ground.  On  the  other  side  the  testicle  is  less  voluminous  and  of  a 
normal  grayish  color. 

By  microscopical  examination  ordinary  lesions  of  the  tuberculous  testicle 
may  be  seen;  the  infiltration  divided  in  more  or  less  disseminated  nodules; 
confluent  in  the  reddish  part  of  the  testicle;  more  discrete  elsewhere.  Among 
the  tuberculous  nodules  one  may  find  the  tubes  curled  up,  with  a  crumpled 
wall,  containing  few  cells,  showing  no  signs  of  spermatogenetic  process.  The 
tubes  that  remain  present  very  accentuated  catarrhal  lesions.  The  most 
peripheral  layer  persists  alone,  with  its  normal  layers,  and  one  may  find  in 
the  tube  an  abundant  hairy  net  with  fine  ramifications,  where  the  seminal 
cells  have  desquamated. 

Exp.  XIII. — Dog  No.  10,  weighing  21.5  kilograms. 

April  15th:  Injection  in  the  spermatic  arteries,  right  and  left,  of  2  c.c. 
of  bouillon  emulsion  of  bovine  bacilli  of  tuberculous  mammitis. 

April  19th:  Both  testicles  are  enlarged.     The  general  state  is  good. 


EXPERIMENTAL   TUBERCULOSIS    OF   TESTICLE. — ESMONET.  329 

May  3cl :  Ablation  of  the  right  testicle  (eighteenth  day) .  Lobulated  ap- 
pearance of  the  testicle.  One  may  see  fine  transparent  granulations,  that 
become  distinctly  of  a  milky  white,  on  the  grayish  background  of  the  testicle 
after  a  short  stay  in  alcohol  or  formalin.  This  testicle  presents  multiple 
nodules  of  tuberculous  interstitial  infiltration,  inclosing  a  good  many  tubes. 
The  tubes  are  desquamating  everywhere.  In  this  desquamating  epithelium 
one  may  find  a  few  pseudo-giant-cells. 

May  4th:  Injection  of  2  c.c.  of  tuberculin. 

May  7th:  Ablation  of  the  left  testicle  (twenty-second  day).  The  ap- 
pearance is  analogous  to  that  of  the  right  one.  The  animal  weighs  22.5 
kilograms. 

The  left  testicle,  by  microscopical  examination,  presents  a  diffuse  tuber- 
culous infiltration,  nearly  equally  divided  between  the  tubes.  The  tubes  are 
desquamated,  except  the  first  layer  of  cells  adherent  to  the  wall.  The  hairy 
net  is  abundant.     One  may  see  a  very  marked  thickening  of  the  vascular  walls. 

Exp.  XIV. — Dog  No.  14,  weighing  25  kilograms. 

April  1st:  Injection  of  the  right  and  left  spermatic  arteries  with  1  c.c. 
of  human  tuberculosis  emulsion. 

April  19th:  Weight,  20.4  Idlograms.  The  right  testicle  is  hard  and  firm. 
The  left  one  is  not  easily  perceptible  on  account  of  a  very  marked  edema. 
The  wound  suppurates  abundantly. 

April  29th:  Ablation  of  the  left  testicle  (twentieth  day).  It  is  firm,  pre- 
senting nodosities  of  the  volume  of  a  pea,  whitish,  hard,  inclosed  in  a  paren- 
chyma more  gray  than  normal.  These  nodules  are  especially  scattered  at 
the  periphery  of  the  testicle.  In  one  point  they  conglomerate  and  form  a 
hard  nucleus  of  the  volume  of  a  small  hazelnut. 

The  microscopical  aspect  is  exactly  the  same  as  that  of  the  left  testicle 
described  in  the  fifteenth  experiment.  In  both  of  them  one  may  see  the 
same  interstitial  infiltration  with  polynuclear  leukocj^es  and  numerous 
mononuclear  elements,  lymphocytes  especially,  the  same  desquamative 
process  of  the  epithehum,  and  the  same  aspect  of  false  giant-cells  due  to  this 
desquamation,  the  same  abundance  of  Koch's  bacilli  infiltrating  the  whole 
tissue.  The  epithelial  desquamation  shows  all  the  intermediary  stages  de- 
scribed. This  testicle  contains  no  glycogen,  except  on  a  level  with  the  tu- 
bercles that  contain  much  of  it.- 

The  right  testicle  is  taken  away  on  June  8th  (sixty-eighth  day  after  the 
intervention).  The  wound  suppurated  without  interruption;  the  animal 
grew  thin.     It  weighs  20.8  kilograms. 

The  testicle  is  atrophic,  the  size  of  a  hazelnut.  It  presents  voluminous 
cicatricial  loops,  with  but  a  small  amount  of  yellow  testicular  parenchyma. 
This  testicle  contains  no  glycogen.  We  failed  to  find  Koch's  bacilli.  We 
think  that  the  suppuration  has  played  in  some  way  a  curing  part,  not  directly 
on  Koch's  bacilli,  but  by  determining  an  unceasing  afflux  of  migratoiy 
elements,  a  particularly  intensive  and  persistent  reaction  in  all  the  surround- 
ing tissue.  When  the  new  elements  arrived,  injured  in  their  turn  by  the 
necrosing  process,  they  must  have  been  eliminated  by  the  wound,  taking 
out  with  them  the  testicular  tissue  and  the  bacilli. 

Under  these  conditions,  by  doing  away  wdth  the  organ,  general  infection 
seems  to  have  been  avoided.     We  shall  see,  when  describing  the  orchitis 


330  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

produced  by  injections  of  hydro-alcoholic  solution  of  naphthol,  that  we  have 
tried  to  produce  a  curative  process  comparable  to  this  one,  avoiding  the  aid 
of  pyogenic  microbes,  which  may  determine  remote  complications  which 
cannot  be  foreseen. 

Exp.  XV. — Dog  No.  10.  Weighing  21.5  kilograms.  (Testicle  taken 
away  on  the  twenty-second  day.     See  further  on.) 

Exp.  XVI. — Dog  No.  6.     Weighing  25.3  kilograms. 

September  26th:  Injection  in  the  right  and  left  spermatic  arteries,  of 
5  drops  of  bouillon  emulsion  of  tuberculous  mammitis  (bovine). 

September  27th:  Slight  reaction  of  the  testicles. 

October  5th:  There  is  no  more  tumefaction  or  pain. 

October  18th :  Good  general  condition.     The  right  testicle  is  big  and  hard. 

October  29th:  The  general  condition  is  bad.  Weight  24.1  kilograms. 
Ablation  of  the  left  testicle  (thirty-third  day).  It  is  somewhat  enlarged. 
On  a  section,  it  is  pink,  with  numerous  small,  red  points.  Many  whitish 
points  of  the  size  of  a  pin's  head  may  be  seen.  In  the  epididymis  a  big 
whitish  and  hard  nucleus.  No  focus  undergoing  caseation.  On  microscopical 
examination  one  may  note  the  infiltration  of  most  of  the  testicle  in  more  or 
less  extensive  plaques,  where  no  remainder  of  tubes  may  be  found.  Poly- 
nuclears  and  lymphocytes  form  the  greater  part  of  that  infiltration.  On  the 
periphery  of  the  infiltration  one  may  recognize  tubes  where  remain  the  last 
vestiges  of  seminal  epithelium.  The  hairy  net  is  abundant  and  fine.  Some 
tulles,  the  walls  of  which  seem  to  be  very  little  or  not  at  all  injured,  are  filled 
with  the  cellular  elements  that  form  the  infiltration.  It  appears  that  the 
wall  of  the  tube  has  given  way  at  another  point  than  that  through  which 
the  section  is  made,  and  that  the  infiltration  has  passed  through  the  lumen 
of  the  tube. 

The  animal  grew  thin  during  the  following  weeks.  It  became  cachectic, 
and  died  in  the  night  of  November  16th  (fifty-second  day  after  injection). 
At  the  post-mortem  the  spleen  is  large,  red,  and  firm.  The  liver  presents 
alternately  red  and  yellow  color.  Fine  transparent  tubercles  on  the  pleura 
and  peritoneum.  The  kidneys  are  yellowish  and  show  biliary  infiltration. 
The  urine  is  icteric  and  presents  Gmelin's  reaction.  Nothing  in  the  spermatic 
vessels  nor  in  the  bladder. 

Ablation  of  the  right  testicle  (fifty-second  day).  It  is  not  very  much  en- 
larged, but  very  hard.  There  is  no  liquid  in  the  tunica  vaginalis  testis. 
The  albuginea  is  thickened.  On  section  of  the  testicle  numerous  spots  of 
a  golden  yellow,  fi-om  the  size  of  a  pin's  head  to  that  of  a  little  pea,  show  dis- 
tinctly on  the  grayish  groimd.  Same  granulations  on  the  epididymis.  The 
testicle,  put  in  formalin  in  contact  with  the  air,  shows  after  some  hours,  in- 
stead of  the  golden  yellow  spots,  some  greenish  spots  due  to  the  changes  of 
the  bile. 

When  one  looks  through  the  section  with  the  naked  eye  one  may  see,  in 
a  preparation  colored  with  hematin-eosin,  the  caseous  nuclei  forming  very 
broad  and  irregular  spots  feebly  stained  pink.  In  the  intervals  the  infiltrated 
and  not  yet  caseous  parts  are  more  or  less  intensely  stained  by  hematin. 

With  a  lens  one  may  find  in  the  caseous  foci  a  great  number  of  Koch's 
bacilli.  The  tiny  part  of  infiltrated  testicular  parenchyma  is  filled  with 
Koch's  bacilli. 


EXPERIMENTAL  TUBERCULOSIS   OF   TESTICLE. — ESMONET.  331 

Exp.  XVII.— Dog  No.  11.     Weighing  27  kilograms. 

January  11th:  Injection  in  the  spermatic  artery  of  4  drops  of  a  dilution 
containing  a  few  Koch's  bacilli  (human).  On  the  left,  injection  of  two  drops. 
No  inflammatory  reaction  with  respect  to  the  testicles;  they  present  but  little 
tenderness.  The  general  state  remains  good,  though  the  animal  gets  thin. 
It  weighs  23  Idlograms  on  Februaiy  23d,  when  both  testicles  are  taken  out 
(forty-second  day). 

By  microscopical  examination  one  may  see  that  the  testicle  is  normal 
almost  throughout.  The  epithelium  presents  numerous  spermatozoa.  At 
some  points  one  may  find  a  very  discrete  beginning  of  embryonic  infiltration 
in  the  interstitial  tissue.  On  that  level  the  neighboring  tubes  present  an 
acute  epithelial  desquamation,  there  are  no  more  spermatozoa,  and  in  the 
tube  some  giant  forms  may  be  found. 

We  must  attribute  the  small  extent  of  the  lesions  to  the  small  amount 
of  bacilli  we  injected.  If  we  had  injected  bovine  tuberculosis,  it  is  probable 
that  the  lesions  w^ould  have  been  more  distinct. 

Exp.  XVIII. — Dog  No.  12.     Weighing  16  kilograms. 

September  23d:  Injection  in  the  right  and  left  spermatic  arteries  of  2  c.c. 
of  bouillon  dilution  of  human  tuberculosis.  Slight  inflammatory  reaction 
in  both  testes,  especially  in  the  left  one,  wliere  the  pain  is  veiy  sharp. 

October  5th:  Good  general  condition.  Ablation  of  the  right  testicle 
(twelfth  day)  very  firm,  somewhat  pink,  bleecUng  when  it  is  cut.  By  histo- 
logical examination,  discrete  and  slight  infiltration  in  the  interstitial  tissue, 
with  easily  stained  bacilli.  The  epitheUum  is  about  to  desquamate,  but  some 
cells  remain  in  the  tubes,  and  the  forms  of  giant  desquamative  cells  are 
abundant. 

October  19th:  The  dog  died.  Autopsy  on  the  20th:  The  left  testicle 
(twenty-seventh  day)  presents  a  caseous,  wliitish  block  fitted  in  a  crescent 
of  less  altered  parenchyma.  Everywhere  the  testicle  is  affected  with  edema. 
Macroscopically  nothing  can  be  seen  in  the  viscera  except  in  the  liver,  which 
is  alternately  red  and  yellow,  instead  of  presenting  the  uniform  red  color 
usual  in  dogs. 

Microscopical  examination  of  the  non-caseous  testicular  parenchyma 
shows  a  complete  necrosis.  Everytliing  is  colored  in  the  same  way  by  eosin, 
including  the  cells  forming  the  infiltration,  except  on  a  very  limited  spot 
where  numerous  polynuclears  are  stained.  Generalized  granulia  in  the  lungs, 
liver,  and  kidneys,  verified  by  microscopical  examination  and  by  the  colora- 
tion of  Koch's  bacilli. 

Exp.  XIX. — Dog  No.  6.  Caseous  testicle  (fifty-second  day).  (See 
18th  exp.) 

Exp.  XX. — Dog  No.  7.     Weighing  25  kilograms. 

January  17th:  Injection  in  the  right  and  left  spermatic  arteries  of  1  c.c. 
of  emulsion  of  bacilli  of  human  tuberculosis.  TMs  dog,  very  emaciated  at 
the  time,  died  on  the  next  day.  Nothing  is  found  in  the  organs.  The  tes- 
ticles have  their  normal  appearance.  The  interstitial  tissue  is  normal.  The 
seminal  tubes  present  their  normal  epithelium  with  numerous  spermatozoa. 
Perhaps  there  is  a  very  slight  degree  of  seminal  catarrh.  It  seems  that  there 
is  in  the  spermatic  magma  an  abnormal  number  of  immature  elements  or 
spermatocytes. 

Exp.  XXL— Dog  No.  9.     Weighing  25  kilograms. 


332  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

February  1st :  Injection  in  both  spermatic  arteries  of  10  drops  of  bouillon 
emulsion  of  human  bacilli. 

February  25th:  Very  good  general  condition.  Ablation  of  the  left 
testicle  (twenty-fifth  day).  No  lesion  may  be  found  in  the  testicle.  The 
tubes  have  their  normal  aspect,  spermatozoa  are  numerous,  the  interstitial 
tissue  presents  no  mochfication.  This  testicle,  except  on  a  level  with  some 
rare  tubes,  contains  no  glycogen. 

March  15th:  Weight  23  kilograms.  Ablation  of  the  right  testicle 
(forty-third  day).  Normal  aspect,  somewhat  firmer  consistency.  On 
section,  two  or  three  reddish  points.  By  microscopical  examination  one  may 
ascertain  the  presence  at  such  a  point  of  a  small  nodule  of  embryonal  infiltra- 
tion, presenting  numerous  polynuclears  and  lymphocytes  with  peripheral 
congestion.     It  contains  no  colorable  Koch's  bacilli. 

We  cannot  explain  the  complete  failure  of  the  injection  for  the  left  testicle. 
The  animal,  killed  some  time  after  other  experiments,  presented  no  trace 
of  tuberculization. 

In  short,  the  injections  of  tuberculosis  (human  or  bovine)  in  the  sper- 
matic artery  have  in  nearly  all  the  cases  determined  an  extensive  tubercu- 
lization and  Idlled  the  animal  by  propagation  of  the  tuberculosis  to  other 
viscera.  The  results  given  by  these  injections  show  that  the  inflammatory 
reactions  of  the  testicle  are  changeable,  but  generally  not  intense.  The 
testicles,  in  the  daj^s  that  follow  the  injection,  are  somewhat  large  and  painful, 
but  these  symptoms  quickly  disappear;  and  after  five,  six,  or  ten  days 
nothing  more  is  appreciable. 

As  for  the  general  concUtion,  during  some  time  it  is  satisfactory.  Our 
dogs,  coming  from  the  police  station,  were  not  in  a  very  good  condition, 
and  most  of  them,  in  the  days  following  the  injection,  have  grown  fatter. 
We  have  found  no  appreciable  lesions  in  dogs  whose  testicles  have  been  ex- 
amined soon  after  death  (exp.  No.  XX) — twenty-four  hours,  for  instance. 
No  interstitial  or  epithelial  reaction  was  histologically  appreciable,  and  we 
could  discover,  with  difficulty,  some  bacilli  colored  with  Ziehl's  reagent 
disseminated  in  the  intertubular  tissue. 

After  seven  days  (exp.  No.  XI)  one  may  recognize  microscopical  lesions, 
the  testicle  is  congested,  presents  small  white  points,  somewhat  difficult  to 
distinguish  at  first  sight,  but  which  become  very  visible  after  a  short  stay  in 
formalin  or  alcohol  at  60°  or  90°.  So  after  seven  days  the  tuberculous  nod- 
ules may  sometimes  be  detected  in  the  interstitial  tissue  of  the  testicle. 
Yet  there  is  a  marked  proliferation  of  the  elements  of  the  connective  tissue, 
but  we  specially  note  the  presence  of  large  quantities  of  polynuclear  leuko- 
cytes, with  mononuclears  and  especially  lymphocytes. 

The  tubes  near  the  tuberculous  infiltration  are  affected  in  a  great  number 
of  cases.  The  tubes  somewhat  far  from  the  nodules  seem  unaffected,  and 
present  a  normal  epithelium  containing  much  glycogen,  and  as  much  fat  in 
the  seminiparous  epithelium  as  in  the  interstitial  cells. 


EXPERIME^rTAL  TUBERCULOSIS   OF  TESTICLE. ESMONET.  333 

It  is  sure,  contrary  to  former  opinions,  and  according  to  actual  histo- 
logical observations  as  to  the  pseudo-endothelium  of  the  seminial  canaliculi, 
that  the  development  of  the  tubercle  takes  place  in  the  connective  tissue,  by- 
means  of  mesodermic  elements  of  hematic  or  connective  tissue  origin.  They 
infiltrate  the  interstitial  tissue,  find  their  way  between  the  tubes,  and  surround 
them  completely.  Tliis  is  exactly  the  mode  of  invasion  we  found  on  a  level 
with  the  variolous  nodule.  Tuberculosis  of  the  testis  has  never  injured  a 
tube  at  the  beginning;  it  affects  several  of  them  at  the  same  time,  almost 
always  in  the  part  near  to  the  intertubular  zone  invaded  by  the  disease. 
On  the  seventeenth,  eighteenth,  or  nineteenth  day,  the  lesions  generally 
show  distinctly,  as  much  in  the  tubes  as  in  the  epithelium.  At  this  time 
the  tuberculous  infection  generally  reaches  nearly  all  the  interstitial  tissue. 
The  tubes  disappear  amidst  the  nodules,  and  those  that  are  not  yet  com- 
pletely invaded  present  advanced  lesions  of  their  epithelium,  comparable  to 
those  we  found  in  man  during  smallpox,  though  differing  in  a  few  characters. 

At  times,  in  fact,  the  epithelium  of  the  tubes  becomes  necrosed  en  masse. 
Everything  desquamates  at  the  same  time  and  falls  in  the  lumen  of  the  tube. 
Protoplasm  and  nuclei  stain  no  more.  Along  the  wall  remain  a  few  cells, 
with  abundant  protoplasm,  a  voluminous,  compact,  and  feebly  colored 
nucleus.  We  find  these  cells  in  all  the  cases  of  seminal  catarrh,  observed 
as  often  in  man  as  in  animals. 

Sometimes  the  cells  remain  only  along  the  walls;  more  often  one  may  see 
long  and  thin  entangled  filaments,  the  remainder  of  the  homogeneous  inter- 
cellular tissue  of  the  normal  seminal  epithelium;  sometimes  this  substance 
has  been  injured  at  the  same  time  as  the  cells,  and  everything  has  desqua- 
mated together;  but  more  often  it  holds  out  and  lets  go  the  cells  it  contained 
as  in  a  net,  and  then  a  fine  and  slender  hairy  plexus  remains. 

Often  the  necrosing  process  injuring  the  epithelial  cells  produces  volum- 
inous cellular  forms,  which  resemble  giant-cells,  but  are  easily  differentiated 
by  the  aspect  of  their  protoplasm  and  of  their  nuclear  remains.  These  forms 
of  seminal  catarrh  are  especially  numerous  in  the  tubes  at  the  periphery  of 
the  tuberculous  nodule. 

After  the  very  quick  fall  of  spermatozoa  and  spermatids,  after  some 
spermatocytes,  presenting  their  normal  nucleus,  have  desquamated,  the 
cells  still  retained  in  the  hairy  plexus  show  a  protoplasm  with  more  or  less 
distinct  outlines,  and  especially  a  peculiar  state  of  the  nuclear  filament  that 
swells  up  to  three  or  four  times  its  normal  size.  This  modification  may  affect 
the  nuclear  filament  in  one  of  the  stages  of  spermatogenesis,  causing  infinite 
diversity  in  the  forms  of  necrosis.  It  reminds  of  spermatogonia,  spermato- 
cytes, or  giant  spermatids.  That  filament  stains  very  strongly,  and  keeps  for 
a  long  time  this  character,  like  the  spermatozoa  one  may  find  in  the  testicular 
magma. 


334  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

The  tubes  inclosed  in  the  nodule  itself  present  but  a  few  cells  joined  to  the 
wall  and  a  more  or  less  distinct  hairy  plexus.  The  intertubular  proliferation 
invades  the  layers  of  the  wall,  creeps  between  them,  bursts  out  in  the  tube, 
which  it  makes  unrecognizable  after  a  few  days. 

The  interstitial  tissue,  during  the  weeks  that  follow,  presents  the  same 
characters.  The  leukocytic  infiltration  with  polynuclear  cells  prevails, 
though  the  number  of  cells  with  one  nucleus,  and  especially  lymphocytes, 
seems  to  increase.  Little  by  little  all  the  elements  of  the  nodule  take  less 
color.  Karyolysis  is  much  accentuated.  Caseation  of  the  tuberculous  nod- 
ule happens,  and,  soon  after,  only  the  numerous  heaps  of  Koch's  bacilli 
may  be  well  stained  in  that  caseous  focus. 

At  this  moment,  if  one  looks  by  transparency  at  a  stained  section,  one 
may  clearly  see  the  caseous  foci,  disseminated  in  the  whole  testicle,  and  some- 
times confluent,  so  as  to  leave  only  narrow  bands  of  infiltrated  tissue  replac- 
ing the  testicular  parenchyma. 

At  no  time,  and  it  seemed  to  us  in  no  organ,  does  the  dog  present  the 
giant-cell  so  frequent  in  tuberculosis  of  man  and  the  guinea-pig.  We  have 
been  struck  by  the  long  resistance  of  interstitial  cells  inclosed  in  the  tuber- 
culous nodule.  In  preparations  stained  with  osmic  acid  they  are  clearly 
visible  four  or  five  weeks  after  the  injection,  when  the  tubes  have  completely 
disappeared. 

While  these  lesions  are  going  on  in  the  testicle,  the  rest  of  the  organism 
is  affected  by  tuberculosis.  Generally  the  testicle  becomes  caseous  toward 
the  eighth  or  ninth  week.  At  this  time  the  animal  is  very  sick,  and,  after 
death,  presents  a  generalized  granulia,  specially  perceptible  about  the  liver,* 
the  lungs,  the  bladder,  the  pleura,  and  the  peritoneum.  In  all  the  cases 
where  the  quantity  of  tuberculous  bacilli  injected  in  the  spermatic  artery 
is  sufficient  to  determine  an  acute  tuberculosis  we  have  obtained  generaliza- 
tion in  a  short  time.  It  seems  that  with  equal  doses  of  microbes,  tuber- 
culization occurs  more  quickly  in  this  way  than  by  injection  into  the  general 
venous  system.  The  testicle  is,  for  Koch's  bacilli,  a  culture-medium  very 
favorable  in  the  dog,  and  the  bacteriological  examination  seems  to  confirm 
this  opinion.  In  fact,  the  quantities  of  injected  culture  were  practically 
equal,  being  gathered,  emulsioned,  injected  in  similar  conditions.  Bac- 
teriological examination,  made  a  very  short  time  after  the  injection,  showed 
but  a  small  quantity  of  Koch's  bacilli;  after  a  long  time  there  were  many 
bacilli — a  fact  which  we  must  attribute  to  the  growth  of  bacilli  in  situ.     A 

*  In  several  cases,  dogs  have  presented  a  remarkable  icterus,  recognizable  in  the 
yellowish  color  of  the  sclerotic,  by  the  dark  urine,  giving  Gmelin's  reaction.  At  autopsy 
the  organs  presented  a  variable,  sometimes  very  distinct,  degree  of  biliary  imbibition. 
In  the  sixteenth  experiment,  especially,  the  caseous  nuclei  of  the  testicle  were  colored 
yellow,  which  became  of  a  clear  green  after  some  hours  in  a  solution  of  formalin  ex- 
posed to  air. 


EXPERIMENTAL  TUBERCULOSIS   OF   TESTICLE. — ESMONET.  335 

feeble  dose  of  bacilli  injected  in  a  dog's  testicle  produces  sometimes  granulia 
and  death  more  quickly  than  injection  into  the  general  venous  system.  We 
have  no  data  about  the  rapidity  with  which  the  tuberculization  takes  place 
through  the  pleura  or  peritoneum. 

We  must  describe  another  peculiar  point  in  the  tuberculization  by  human 
bacilli  and  the  bacilli  coming  from  the  tuberculous  mammitis  of  cows.  The 
dog  seems  more  sensitive  to  the  latter  than  to  the  former;  while  the  guinea- 
pig  reacts  as  readily  to  the  one  as  to  the  other.  In  dog  No.  11,  for  instance, 
very  small  doses  (2  or  4  drops  of  bouillon  emulsion  of  bovine  tuberculosis) 
caused  special  nodules,  which  similar  injections  made  with  bacilli  of  human 
tuberculosis  could  not  have  caused.  According  to  Nocard  and  Leclainche, 
the  dog  does  not  react  to  intravenous  and  intraperitoneal  injections  of 
tubercle  bacilli  from  birds. 

Injections  of  tuberculin  made  under  the  skin  during  the  experimental 
tuberculosis  of  the  testicle  do  not  seem  to  produce  any  histological  change 
showing  after  four  days  (dog  No.  10,  exp.  XIII).  It  appears  that  to  study 
the  local  reactions  of  the  tuberculous  nodule  to  tuberculin,  the  method  of 
intraspermatic  injections  is  preferable  to  any  other  process. 

We  tried  to  find  out  which  would  be  the  results  of  ablation  of  the  testicles 
after  experimental  tuberculization,  and  whether  the  generalization  could  be 
avoided  in  this  way.  In  dogs  where  the  ablation  of  tuberculous  testicles  has 
been  done  on  the  seventh,  eighteenth,  or  twenty-second  day,  we  could  find 
no  tuberculosis  in  other  parts  of  the  body.  The  animals  continued  in  good 
health,  and  when  killed  for  experiment  of  another  kind,  they  presented  no 
sign  of  tuberculosis. 

In  dogs  where  the  ablation  of  the  testicle  was  performed  only  after  forty- 
two,  forty-five,  fifty-two,  and  sixty-eight  days  we  found  on  post-mortem 
examination  a  generalized  granulia.  Those  that  were  not  killed  at  that 
moment  demonstrated  by  their  emaciation  that  tuberculosis  was  not  con- 
fined to  the  testicle.  In  one  case,  although  the  testicles  had  been  taken  away, 
one  on  the  twelfth,  the  other  on  the  twenty-sixth  day,  the  animal  died  of 
generalized  tuberculosis.  In  another  dog  the  general  condition  on  the  forty- 
fifth  day  was  satisfactory,  notwithstanding  a  slight  emaciation.  In  the  first 
case  we  had  injected  2  c.c,  in  a  second  10  drops  of  bouillon  emulsion  of  human 
tuberculosis.  One  concludes  from  these  data  that  a  comparatively  early 
ablation  of  the  tuberculized  testicles  of  a  dog  prevents  generalization  in  nearly 
all  the  cases. 

5.  Injections  of  Koch's  Tuberculin  in  the  Spermatic  Artery. 

Exp.  XXII. — Dog  No.  18.     Weighing  35  kilograms. 
November  28th:  Injection  in  the  right  spermatic  artery  of  1  c.c.  of  tuber- 
culin in  2  c.c.  of  bouillon;  and  in  the  left  spermatic  artery,  10  drops  of  non- 


336  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

diluted  tuberculin.  On  the  following  day  the  testicles  are  very  swollen  and 
painful. 

December  10th:  Tumefaction  and  pain  have  disappeared. 

December  20th:  The  testicles  are  no  more  painful,  but  they  seem  some- 
what hard. 

January  12th  (forty-fifth  day):  Ablation  of  both  testicles.  On  the  right 
side  the  testicle  must  be  dissected  out  of  the  fibrous  mass  which  surrounds 
it.  The  whole  gland  is  indurated.  On  the  left  side  the  enlarged  testicle 
shows  only  a  few  adhesions  of  sclerosis.  Epithelium  contains  no  spermato- 
genetic  forms.  Spermatozoa  and  spermatids  are  missing.  In  the  rest  of 
the  epithelium,  very  compact,  the  nuclei  of  the  cells  are  somewhat  different 
as  you  examine  the  most  axial  or  the  most  peripheral  stratum.  The  nuclei 
of  the  cells  corresponding  to  the  layer  of  spermatogonia  is  homogeneous  and 
deeply  colored.  The  cells  of  the  most  internal  layer  present  a  nucleus  whose 
chromatic  filament  is  feebly  colored,  equally  distributed  through  the  nucleus, 
without  presenting  the  evolution  forms  of  the  normal  spermatocyte. 

The  vascular  walls  are  very  much  thickened.  The  examination  by 
osmic  acid  shows  that  these  cells  are  filled  up  with  fat,  more  abundant  than 
is  normal  and  disposed  in  unequal  droplets,  attesting  an  acute  granular  and 
fatty  degeneration. 

Exp.  XXIII.— Dog  No.  19.     Weighing  27  kilograms. 

April  23d:  Injection  in  the  left  spermatic  artery  of  5  drops  of  tuberculin 
in  2  c.c.  of  bouillon;  in  the  right  spermatic  artery,  30  drops  of  tuberculin  in 
2  c.c.  of  bouillon. 

A]Dril  25th:  Both  testicles  are  large  and  painful. 

May  3d:  Ablation  of  the  right  testicle  (thirteenth  day).  This  testicle 
is  completely  necrosed.  All  the  central  part  is  stained  pale  pink  by  hematin- 
eosin.  The  periphery  presents  an  area  4  or  5  millimeters  broad,  of  deep 
infiltration,  of  leukocytes  which  are  for  the  most  part  polynuclears.  All  the 
leukocytes  are  united,  and  give  the  preparation  an  aspect  similar  to  what 
we  have  noticed  after  the  intraspermatic  injections  of  Eberth's  toxin. 

June  6th  (forty-second  day),  ablation  of  the  left  testicle.  It  is  of  a  brown- 
ish color,  hard,  with  sclerous  bands  surrounding  the  lobules.  The  periphery 
of  the  testicular  parenchyma  is  of  a  yellov/ish  color,  perhaps  a  vestige  of 
former  hemorrhages. 

The  results  given  by  injection  of  Koch's  tuberculin  in  the  spermatic 
arteries  may  be  summarized.  After  an  immediate  inflammatory  reaction, 
which  may  go  as  far  as  complete  necrosis  of  the  gland  (Exp.  XXIII,  right 
testis),  the  inflammatory  phenomena  quickly  mend  in  ten  or  twelve  days. 
A  sclerosing  process  peculiarly  intense  and  with  a  quick  evolution  affects  the 
testicle  partly  (Exp.  XXIII,  left  testicle)  or  wholly  (Exp.  XXII,  right  testicle) 
from  the  fort3^-second  and  forty-fifth  day.  The  effect  on  the  testicle  may  be 
less  severe,  either  by  reason  of  greater  dilution  of  the  tuberculin,  or  rather 
by  the  exposure  of  this  tuberculin,  for  some  time,  to  air  and  sunshine.  The 
left  testicle  of  the  dog  No.  18  (Exp.  XXII)  shows  but  a  small  reaction  in 
the  interstitial  tissue.  In  the  epithelium,  if  it  is  completely  desquamated 
from  the  beginning  and  mends  little  by  little,  or  if  the  same  initial  lesions 


EXPERIMENTAL  TUBERCULOSIS   OF   TESTICLE. — ESMONET.  337 

persist  during  a  long  time,  its  spermatogenetic  function  is  abolished,  and  the 
presence  of  spermatids  and  spermatozoa  can  no  more  be  detected.  Besides, 
a  fact  that  may  seem  less  in  favor  of  an  epithelial  restoration  than  of  a  slow 
degeneration,  the  cells  present  a  great  number  of  fatty  granulations. 

We  have  begun  examining  the  reaction  of  the  testicle,  after  punctures, 
intradeferential  injections,  and  intraspermatic  injections,  with  regard  to 
tuberculous  poisons,  ethero-bacillin,  chloroformo-bacillin,  which  M.  Auclair 
has  been  kind  enough  to  give  us. 

6.  Injections  of  Naphthol  Through  the  Spermatic  Artery  in  the 

Normal  Testicle. 

Exp.  XXIV. — Dog  No.  33,  weighing  15  kilograms. 

October  7th:  Injection  in  the  right  and  left  spermatic  arteries,  of  10 
drops  of  hydro-alcoholic  solution  of  naphthol.  On  the  following  days  both 
testicles  are  very  swollen  and  painful. 

October  25th  (eighteenth  day):  Both  testicles  are  very  soft.  The 
right  testicle  is  taken  away.  It  is  red,  congested  everywhere,  but  especially 
in  some  regions,  having  the  shape  of  wedges  directed  toward  Highmore's 
body.  By  microscopical  examination  the  appearance  of  this  testicle  re- 
sembles the  testicles  taken  away  a  short  time  after  ligature  of  the  spermatic 
artery.  It  differs,  however,  by  the  fact  that  the  considerable  increase  of 
interstitial  tissue  is  due  not  to  hemorrhage,  but  to  an  acute  infiltration, 
mostly  of  polynuclear  leukocytes.  The  proliferation  of  the  cells  of  connec- 
tive tissue  is  not  very  well  marked.  The  epithelium  of  the  seminiparous 
tubes  is  necrosed.  It  takes  no  color.  The  cells  form  a  homogeneous  block 
in  the  tubes.  The  split  cells  set  free  the  fat  in  the  tubes,  in  the  connective 
spaces,  in  the  lymphatic  vessels,  in  the  veins. 

October  26th:  The  animal,  which  seems  to  be  sick  and  has  lost  1  kilogram 
of  weight,  is  killed.  The  left  testicle  is  taken  away  (nineteenth  day).  A 
part  of  the  testicle,  although  somewhat  pink,  seems  normal.  The  remains 
present  reddish  foci  comparable  to  those  of  the  first  testicle.  Histological 
examination  gives  the  same  results  as  for  the  right  testicle. 

Exp.  XXV. — Dog  No.  40,  weighing  17  kilograms. 

July  1st:  Injection  of  10  drops  of  hydro-alcoholic  solution  of  naphthol  in 
both  spermatic  arteries.  During  the  following  days,  tumefaction  and  pain 
in  the  scrotum.     The  animal  is  not  in  good  health. 

July  15th:  The  dog  seems  to  get  better.     It  weighs  16.2  kilograms. 

November  12th:  Both  testicles  are  very  small  and  hard,  they  cannot  be 
easily  perceived  through  the  scrotum,  they  are  retracted  toward  the  external 
inguinal  ring.  When  taken  away,  they  appear  of  the  size  of  a  bean,  very 
hard,  sclerosed,  and  difficult  to  cut.  In  some  places  a  small  quantity  of 
testicular  parenchyma  persists  of  a  yellowish  tint,  showing  the  former  exist- 
ence of  hemorrhages  at  this  point.  The  inguinal  glands  shows  nothing  at 
all,  but  the  lumbar  glands  are  smaller  than  usual,  sclerosed,  and  hard  on 
section,  especially  at  the  periphery.  They  have  not  been  examined  histo- 
logically, but  on  section  they  show  a  very  hard  white  cortical  zone,  looking 
like  cicatricial  tissue. 


338  sixth  international  congress  on  tuberculosis. 

7.  Treatment  of  Testicular  Tuberculosis  by  Injection  of  Naphthol 
Through  Spermatic  Artery  in  the  Previously  Tuberculized 

Testicle. 

The  sclerosis  obtained  with  naphthol  drove  us  to  think  that  perhaps  the 
evolution  of  the  testicular  infection  due  to  Koch's  bacilli  could  be  modified  in 
a  favorable  way. 

Exp.  XXVI. — Dog  weighing  22  kilograms. 

October  7th:  Injection  of  1.5  c.c.  of  bouillon  emulsion  of  Koch's  bacilli 
in  the  left  spermatic  artery. 

October  25th:  The  animal  is  healthy.  It  weighs  only  20  kilograms. 
The  left  testicle  is  harder  than  the  right  one. 

October  26th  (nineteenth  day  after  tuberculization) :  We  inject,  in  the 
left  spermatic  artery,  10  drops  of  a  hydro-alcoholic  solution  of  naphthol. 
In  the  following  days  the  inflammatory  reaction  is  intense;  the  testicle 
is  very  large  and  painful.  The  animal  refuses  to  eat.  But  toward  November 
7th  or  8th  all  the  inflammatory  phenomena  give  way  again,  the  general 
condition  gets  better  and  becomes  very  satisfactory. 

January  9th:  The  animal  is  Idlled;  it  weighs  25  kilograms.  The  left 
testicle  has  come  to  the  volume  of  a  bean.  It  is  firm,  sclerosed.  One  may 
find,  by  coloration  with  Ziehl,  no  bacilli  in  the  nodules,  with  small  round  cells 
which  are  found  in  great  number  as  vestiges  of  the  infectious  foci  that  must 
have  been  in  the  parenchyma.  No  tuberculosis  anywhere  else  in  the  viscera. 
The  injections  of  naphthol  in  the  spermatic  arteries  have  caused  a  beginning 
of  sclerosis  in  the  lumbar  ganglia,  corresponding  with  the  injected  testicle. 
So  a  part  of  naphthol  has  been  carried  away,  we  do  not  know  under  what 
form,  by  the  lymphatic  vessels. 

The  injection  of  naphthol  has,  in  this  case,  stopped  the  generalization  of 
tuberculosis,  as  well  and  in  the  same  time  as  the  ablation  of  the  testicle. 

8.  Injections  of  Infected  Cultures  of  Tuberculosis. 

In  the  following  observations  we  produced — unexpectedly — a  gangren- 
ous orchitic  process,  and  peritoneal  and  general  infections,  complications 
which  we  think  necessary  to  describe,  for,  if  they  show  that  the  least  failure 
in  asepsis  wholly  changes  the  results  of  those  intraspermatic  injections,  we 
think  also  that  they  allow  to  believe  that  the  lesions  obtained  with  a  good 
technic  are  due  to  the  injected  media. 

We  notice  also  that  those  accidents  happened  in  a  series,  during  experi- 
ments made  March  11th  and  25th  and  April  1st.  We  think  they  were  due 
to  the  infection  of  the  very  culture  of  tuberculosis  we  have  used,  and  they 
happened  no  more  when  we  ceased  to  use  that  culture. 

Exp.  XX VII.— Dog  No.  21.     Weight  20.4  kilograms. 
March  25th:   Injection  in  the  right  and  left  spermatic  arteries  of  1.5  c.c. 
of  bouillon  emulsion  of  tubercle  bacilli  of  human  origin. 


EXPERIMENTAL  TUBERCULOSIS   OF   TESTICLE. — ESMONET.  339 

March  2Sth :  Both  testicles  are  enlarged  and  painful. 

March  29th:  Death  in  the  afternoon.  On  post-mortem  examination 
generahzed  peritonitis.  The  left  testicle  is  transformed  into  a  putrid  and 
sanguinolent  pap.  The  right  testicle  is  of  a  generahzed  red  color,  with  large 
circular  patches  of  yellowish  color  especially  at  the  periphery.  All  the 
parenchyma  is  necrosed.  At  the  utmost  one  may  color,  at  the  periphery,  a 
small  breadth  of  interstitial  tissue,  where  numerous  polynuclears  may  be 
found.  Karyolysis  is  intense.  In  the  peripheral  zone  some  tubes  remain, 
the  necrosed  epithelium  of  which  is  completely  desquamated. 

Exp.  XXVIIL— Dog  No.  22,  weighing  17.3  kilograms. 

April  1st:  Injection  in  the  right  testicle  of  1  c.c.  by  punctures;  in  the  left 
spermatic  artery  1.5  c.c.  of  bouillon  emulsion  of  bacilli  from  human  tuber- 
culosis. The  injection  is  performed  with  some  difficulty  and  a  certain  amount 
of  the  liquid  leaks  along  the  vagino-peritoneal  canal.  In  the  night  April  2d, 
the  dog  died.  Autopsy  on  April  3d  at  10  a.  m.  The  right  testicle  with  its 
multiple  punctures  is  much  enlarged,  with  multiple  and  extensive  hemor- 
rhages, scattered  in  the  whole  testicle.  The  epididymis  is  very  red  and 
large.     No  liquid  in  the  tunica  vaginalis  testis. 

The  left  testicle,  which  had  been  badly  injected,  is  large  and  congested. 
A  coagulum  reaches  the  peritoneal  opening  of  the  vagino-peritoneal  canal, 
and  one  may  see  an  acute  peritonitis  having  already  agglutinated  the  dis- 
tended and  purple-looking  intestinal  loops.  On  microscopical  examination 
one  may  see  that  the  interstitial  tissue  is  the  seat  of  an  edematous  infiltra- 
tion and  an  acute  fibrino-leukocytic  exudate.  The  cells  scattered  in  the 
interstitial  tissue  are  nearly  wholly  necrosed  and  take  color  but  cUffusely. 
In  other  places  a  certain  number  of  polynuclears  seem  to  be  the  last  anatom- 
ical elements  that  persist  (perhaps  because  they  are  formed  the  last) ,  and  one 
may  see  an  acute  karyolysis.  Fine  droplets,  deeply  colored  by  basic  stains, 
represent  vestiges  of  the  nuclei. 

The  wall  of  the  seminiferous  tubes  wrinkles  around  the  tul^e.  The  wall 
itself  seems  nearly  untouched,  but  the  seminal  epithelium  is  wholly  necrosed. 
Spermatozoa  alone  take  the  stain  deeply.  All  the  epithelial  cells  come  off. 
In  some  tubes  the  same  thing  happens  for  the  nuclei  of  the  spermatogenetic 
cells.  For  the  polynuclears  of  the  interstitial  cells.  There  are  a  great  num- 
ber of  small  droplets,  deeply  colored,  representing  nuclei  about  to  divide  in 
the  seminal  epithehum.  We  found  no  trace  of  glycogen  in  either  of  the  tes- 
ticles. 

Exp.  XXIX. — Dog  No.  23,  weighing  7.8  kilograms. 

March  11th:  Injections  in  the  right  and  left  spermatic  arteries  of  1.5  c.c. 
of  bouillon  dilution  of  Koch's  bacilli  from  human  tuberculosis. 

March  15th:  Both  testicles  are  swollen  and  painful.  The  left  testicle 
is  transformed  into  a  sanguinolent  pap.  It  bursts  under  the  pressure  of  the 
fingers  when  taken  away.  On  the  periphery  remains  a  layer  or  parenchyma 
immediately  connected  to  the  albuginea  and  of  a  yellowish  tint.  Examina- 
tion shows  long,  voluminous  bacilli,  keeping  color  by  Gram's  method.  The 
same  bacillus  is  found  in  the  putrid  magma  of  the  testicle.  Some  Koch's 
bacilli  may  be  stained,  but  not  easily,  in  the  smears.  The  right  testicle  is 
somewhat  congested  and  is  firm  on  section.  The  testicle  of  this  dog  has  been 
transferred  to  bouillon.  A  bacillus  grew  on  it  more  thickset  than  in  the 
smears,  taking  also  the  Gram,  and  dangerous,  for  it  killed  a  guinea-pig  on 


340  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

the  second  day  after  an  injection  of  1  c.c.  in  the  peritoneum.     That  guinea- 
pig  presented  an  acute  inflammatory  reaction  in  the  peritoneum  and  a  diffuse 
edema  in  the  subperitoneal  and  subcutaneous  cellular  tissue. 
The  study  of  this  microbe  has  not  been  undertaken.* 

9.  Glycogenesis  in  Tuberculosis  of  the  Testicle. 

In  a  former  studyt  we  have  shown  that  glycogen  always  exists  in  the  nor- 
mal cells  of  dog's  and  man's  testicle,  more  particularly  in  the  internal  cells — ■ 
that  is,  in  the  layers  of  spermatids  and  spermatocytes.  It  exists  as  fine  gran- 
ulations in  the  spermatic  pap,  but  disappears  from  the  sperm  in  the  excretory 
canals.  We  have  also  shown  the  variations  of  this  glycogenesis,  according 
to  some  pathological  states,  such  as  the  ligature  of  the  spermatic  cord,  of  the 
spermatic  artery,  of  the  deferent  canal  alone,  etc. ;  or  such  as  the  infections  of 
virulent  microbes  or  active  toxins,  in  the  spermatic  artery  in  the  glandular 
parenchyma,  or  in  the  deferent  canal,  etc.  We  have  studied  the  modifica- 
tions of  glycogenesis  in  tuberculosis  of  the  testicle. 

As  we  have  already  shown  for  the  experimental  tuberculosis  of  the  dog's 
liver,  the  tubercle,  consisting  at  the  beginning  of  a  more  or  less  considerable 
amount  of  polynuclear  white  globules,  is  transformed,  after  three  to  five 
weeks,  into  an  organized  tubercle,  consisting  of  mononuclear  elements,  of 
a  lymphatic  or  connective-tissue  origin  (in  all  cases  mesodermic).|  Some- 
times the  granuloma  appears  sooner.  To  study  the  changes  produced  in 
glycogenesis  of  the  testicle  by  tubercle  bacilli,  examinations  must  be  made  at 
longer  intervals  after  the  injection. 

In  the  spermatic  artery  the  massive  injection  of  10  or  20  drops  of  culture 
of  tubercle  bacilli,  such  as  we  have  made  in  five  cases,  destroys  in  all  cases 
the  glycogen  of  the  cells  of  the  testicle.  Injection  of  tuberculosis  in  the 
deferent  canal,  even  after  ligature  of  the  canal,  determines  no  extensive 
disappearance  of  glycogen  after  thirty-three  days.  By  this  process  the  bacilli 
do  not  diffuse  uniformly.  Puncture  of  the  testicle  with  a  syringeful  of  tuber- 
culous culture  does  not  destroy  glycogen,  except  perhaps  in  a  few  places, 
probably  in  the  track  of  the  punctures.  Lastly,  in  tuberculous  animals 
whose  testicle  presented  no  evident  injury,  the  glycogen  of  the  testicle 
seems  to  have  remained  unaffected. 

On  the  other  hand,  if  one  examines  testicles  of  animals  infected  either 
by  the  spermatic  artery  or  by  the  general  circulation,  or  even  by  puncture 
of  the  gland,  after  forty  or  fifty  days,  that  is,  when  testicular  granulia  or 
massive  fibrous  or  caseous  tuberculosis  is  evident,  one  may  ascertain  the 

♦These  cases  may  be  compared  to  Gosselin's  ulcero-gangrenous  orchitis. 

fLoeper  and  Ch.  Esmonet,  "La  glycogenese  du  testicule,"  Bulletin  Soci^t^  anat- 
omique,  June,  1902. 

ILoeper  and  Ch.  Esmonet,  "La  glycogenese  des  tubercules  granuliques  du  foie  et 
du  testicule,"  Bulletin  Soci6t6  anatomique,  February,  1902. 


EXPERIMENTAL   TUBERCULOSIS   OF   TESTICLE, — ESMONET.  341 

presence  of  glycogen  in  the  cells  that  form  the  tubercle,  and  its  disappearance 
in  the  tubes  of  the  testicle  compressed  and  injured  by  the  tubercles;  so  much 
SO  that  in  case  of  a  very  extensive  granulia,  the  few  tubes  that  remain  are 
completely  deprived  of  gl3"cogen.    We  have  ascertained  that  in  eleven  cases. 

In  these  cases  the  disappearance  of  glycogen  from  the  testicle  is  propor- 
tional to  the  dose  of  microbes  and  to  the  invasion  of  the  organ  by  the  tubercle 
bacilli. 

In  man  we  have  three  times  examined  tuberculosis  of  the  epididymis, 
with  nearly  complete  integrity  of  the  testicle,  which  was  a  little  or  very  much 
glycogenated.  In  one  case  of  tuberculous  granulia  of  the  testicle,  consecu- 
tive to  a  tuberculosis  of  the  epididymis,  only  a  few  tubes  retained  their 
glycogen,  but  nearly  all  the  tubercles  were  glycogenated. 

10.  Fat  IN  Tuberculosis  of  the  Testicle. 
The  systematic  examination  of  fat  in  a  certain  number  of  tuberculous 
testicles  showed  us  that  there  were  generally,  besides  normal  regions  (tubes, 
interstitial  cells),  some  regions  very  much  altered,  where  the  tubes  were  the 
seat  of  a  fatty  obstruction,  and  seemed  unable  to  evacuate  the  products  of 
their  secretion.  One  may  see  interstitial  cells  disappearing  by  the  invasion 
of  a  tuberculous  nodule,  but  in  most  cases  the  interstitial  cell  resists  a  long 
time,  and  one  may  find  in  the  very  nodule  some  cells  retaining  their  fat  with 
its  normal  characters.     It  is  the  same  with  the  fat  of  the  tubes. 

Technic  for  Experimental  Orchitis  Through  the  Spermatic  Artery. 

Infection  of  the  testicle  may  be  experimentally  produced  by  puncture  of 
the  testicle,  injection  in  the  deferent  canal,  or  by  the  blood-vessels.  Most 
of  the  experimental  orchitis  we  have  obtained,  resulted  from  the  injection  of 
infectious  agents  or  poisons  in  the  spermatic  artery. 

We  think  it  useful  to  point  out  the  few  precautions  that  enable  one  to 
operate  easily. 

Technic. — We  choose  a  rather  heavy  dog,  generally  more  than  25  kilo- 
grams, and  the  testicles  of  which  appear  well  developed.  We  induce  anes- 
thesia by  an  injection  in  the  ear  vein  of  a  solution  of  atropin  and  morphin. 
After  having  prepared  the  operation  field,  we  incise  the  skin  immediately 
above  the  place  where  by  palpation  we  feel  the  cord  mixed  up  with  the  epi- 
didymal  bundle.  The  incision,  parallel  to  the  pubic  symphysis,  is  conse- 
quently somewhat  oblique  toward  the  top  and  axis  of  the  bod}^,  in  relation  to 
the  cord  entering  the  inguinal  canal.  The  incision,  2  cm.  long,  respects  the 
abdominal  subcutaneous  layer  and  avoids  any  ligature  or  torsion.  The 
finger  inserted  into  the  wound  very  distinctly  feels  the  cord.  With  a  catch 
forceps  and  a  bistoury,  one  makes  an  incision  through  an  adipose  layer 
about  1  cm.  thick,  and  so  one  reaches  the  cord  surrounded  by  its  fibrous 


342  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

sheath.  One  denudes  the  cord  for  about  1  cm.,  the  fibrous  tunic  is  pinched, 
and  on  the  fold  a  slight  scissors  cut  is  made.  This  incision  is  enlarged,  to 
establish  better  parallelism  with  the  cutaneous  incision.  The  cord,  brought 
out  this  way,  consists  of  two  parts  of  unequal  volume,  joined  by  an  easily 
extensible  and  tearable  meso:  first,  a  posterior  bundle,  with  the  deferent 
canal,  3  mm.  in  circumference  and  with  an  artery;  second,  an  anterior  bundle, 
much  more  voluminous,  where  one  may  see,  under  a  thin  serous  tunic,  the 
arterial  and  venous  bundle. 

The  arterial  branches  are  easily  recognized  by  their  smaller  volume,  their 
sharp  red  color,  their  windings,  sometimes  so  close  that  it  is  hard  to  distin- 
guish the  peripheral  from  the  central  part  of  the  artery.  The  veins,  more 
voluminous,  of  a  blue  black  color,  sink,  whenever  the  vascular  bundle  is 
squeezed,  toward  the  testicle.  The  artery,  on  the  contrary,  remains  full  and 
pulsatile. 

Generally,  when  the  incision  of  the  skin  and  of  the  fibrous  tunic  of  the 
cord  was  higher,  one  fell  upon  a  single  spermatic  artery  that  soon  divided, 
leaving  on  its  way  nearly  imperceptible  arterioles,  which  must  be  spared  to 
keep  the  operative  field  clean.  Same  precautions  for  the  veins.  Without 
these  cautions  the  injection  is  difficult. 

By  drawing  down  the  cord,  one  ordinarily  sees  the  arterial  trunk  single 
or  divided,  but  straight.  It  is  seen  distinctly  enough  through  the  thin  serous 
tunic  to  allow  the  introduction  of  the  needle  of  a  syringe.  We  use  Luer's 
syringe.  We  easily  perceive  the  resistance  and  we  avoid  the  strains  that  tear 
the  artery  and  enlarge  the  hole  in  its  wall.  The  needle,  the  thinnest  possible, 
must  have  a  long  bevel;  it  must  be  very  sharp  and  present  no  trace  of  rust. 
Irido-platinum  needles,  somewhat  larger  for  an  equal  lumen,  appeared  to  us 
inferior  to  steel  needles  carefully  preserved. 

We  seize  the  anterior  bundle  of  the  cord  with  the  left  hand,  we  stretch  it 
with  the  middle  finger.  The  index  finger  is  placed  above  the  vascular  bundle. 
By  drawing  nearer  the  two  fingers  one  may  stop  the  course  of  the  venous 
blood,  and  a  slight  centripetal  pressure  of  the  cord,  made  with  the  right  hand, 
leaves  only  the  artery  filled  up.  These  maneuvers  enable  one  to  operate 
alone.  One  may  use  a  very  smooth  clamp  forceps,  squeezing  the  vascular 
bundle  toward  the  testicle.  An  assistant  takes  it  away  as  soon  as  one  begins 
the  injection.  One  stops  squeezing  the  vascular  bundle  as  soon  as  the  needle 
is  in  the  artery  and  one  begins  the  injection. 

We  perforate  the  artery  as  obliquely  as  possible,  so  as  to  reduce  the 
parallelism  between  the  small  serous  wound  and  the  arterial  wound. 

As  soon  as  the  injection  gets  into  it,  the  artery  gets  white.  Very  often, 
when  the  injection  is  slowly  pushed,  one  may  see  the  blood  diluting  the  solu- 
tion and  sweeping  past  the  point  of  the  needle.     During  the  injection  one 


EXPERIMENTAL   TUBERCULOSIS   OF   TESTICLE. — ESMONET.  343 

must  let  the  cord  go  as  much  as  possible,  so  as  not  to  stop  the  returning  blood. 
When  the  injection  is  over,  one  slowly  takes  away  the  needle. 

Sometimes  (it  seldom  happens  with  the  spermatic  artery)  the  arterial 
wound  loses  but  little  or  no  blood.  This  blood  may  fuse  along  the  artery 
and  the  veins,  without  going  out  of  the  serous  tunic.  More  often  the  blood 
spouts  out.  Sometimes,  with  a  drop  of  collodion,  we  have  been  able  to  shut 
the  puncture,  but  only  when  the  stream  was  small.  Very  often  the  blood 
goes  on  flowing  and  forms  a  clot  in  the  vagino-peritoneal  canal,  sometimes 
filling  the  whole  canal  and  even  reaching  the  peritoneal  cavity. 

For  a  long  time  we  shut  the  operative  wound  in  a  first  (subcutaneous) 
plane  only,  and  afterward  by  a  second  (cutaneous)  plane.  Little  or  no  blood  at 
all  got  in  the  vagino-peritoneal  canal,  but  in  return  a  hemorrhage  of  a  variable 
abundance  infiltrated  the  adjacent  cellular  tissue.  As  we  thought  we 
noticed  that  this  hemorrhagic  exudate  stopped  the  cicatrization  of  the  wound 
and  might  predispose  to  infection,  we  use  now  the  following  process:  When 
we  open  the  common  fibrous  tunic,  we  put  at  the  upper  end  of  the  incision 
of  this  tunic  a  thread  in  form  of  a  U,  of  very  thin  silk,  and  we  leave  the 
thread  untied.  The  same  at  the  inferior  part  of  the  incision.  After  the 
injection  we  tie  the  two  threads.  The  tightening  is  slight  and  the  cord  is 
almost  blood-tight.  The  operative  wounds  recover  very  quickly  and  the 
cord  may  be  easily  found  when  one  wishes  to  do  a  second  injection  on  the 
same  artery. 

We  also  made  experimental  injections  of  sterile  bouillon,  in  doses  of  1 
and  2  c.c,  as  follows: 

Exp.  I. — Dog  of  27.4  kilograms. 

We  performed  an  injection  of  2  c.c.  of  sterilized  bouillon  in  the  left  sper- 
matic artery.  On  the  right  side  the  injection  was  missed  and  we  tied  the 
artery.  The  animal  was  killed  twenty-four  hours  afterward.  The  left 
testicle  presented  a  normal  aspect;  microscopical  examination  shows  the 
entire  soundness  of  the  interstitial  connective  tissue  and  of  the  seminiparous 
epithelium  in  a  state  of  evident  activity. 

On  a  level  with  the  operative  wound,  extending  2  or  3  cm.  into  the  vagino- 
peritoneal canal,  is  a  coagulum  of  blood  molded  in  the  cord. 

Exp.  II. — Dog  weighing  22.2  kilograms. 

An  injection  of  1  c.c.  of  sterile  bouillon  in  both  spermatic  arteries.  The 
right  testicle  is  taken  away  eight  days  afterward;  the  left  one  seventeen 
days  afterward.  Both  are  macroscopically  and  microscopically  unaffected. 
Spermatogenesis  is  very  active.  A  grayish  mass,  easily  dissociated  by  the 
finger,  remains  along  the  cord  on  the  right  side,  3  or  4  cm.  long.  On  the  left 
side  the  cord  is  somewhat  large  and  hard  and  intimately  mixed  up  by  its 
anterior  part  with  the  cellular  tissue  of  the  region.  The  circulation  seems  in 
no  way  hindered.     Both  testicles  bleed  when  cut. 

Exp.  III. — Dog  weighing  15  kilograms. 

The  injection  made  in  the  right  spermatic  artery  (1  c.c.)  showed  an  un- 
affected testicle  ten  days  later. 


344  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

The  effects  obtained  by  injection  of  infectious  and  toxic  substances  by 
this  process  seem  to  be  due  to  the  injected  agents,  and  not  to  the  vehicles. 

Ligature  of  the  Spermatic  Artery. — Fearing  that  some  results  given  by  the 
injections  in  the  spermatic  artery  may  be  considered  as  due  to  a  passing  or 
lasting  obliteration  of  this  artery,  we  have  tried  ligature  of  the  spermatic 
artery,  without  any  action  on  the  testicle. 

Exp.  I. — Dog  No.  38,  weighing  18.4  kilograms. 

October  1st:  Ligature  of  the  right  spermatic  artery.  Testicle  taken  away 
after  twenty-four  hours.  By  microscopical  examination  very  large  hemor- 
rhagic suffusions  are  found  in  all  the  interstitial  tissue.  The  epithelium  of 
the  seminiparous  tubes  takes  much  color;  the  spermatogenetic  stages  are 
easily  recognized  and  spermatozoa  are  numerous.  But  the  union  of  the  cells 
is  about  to  disappear,  and  the  regularly  superposed  strata  begin  to  be  mingled, 
foretelling  the  beginning  of  the  seminal  catarrh.     No  glycogen  found. 

Exp.  II.— Dog  No.  39,  weighing  16.5  kilograms. 

April  15th:  Ligature  of  the  left  spermatic  artery. 

April  19th:  Firm,  large,  and  painful  testicle.  It  is  much  vascularized, 
especially  on  its  central  part.  The  interstitial  tissue  presents  abundant 
hemorrhages.  The  epithelium  of  the  seminiparous  tubes  is  desquamated. 
The  ordinary  strata  of  spermatogenesis  are  not  distinct;  the  anatomical 
elements  take  color  more  diffusely,  although  they  remain  recognizable.  No 
glycogen. 

Exp.  III. — Dog  No.  37,  weighing  8  kilograms. 

July  14th:  Ligature  of  both  spermatic  arteries. 

July  17th:  Ablation  of  the  left  testicle.  This  testicle  is  congested,  very 
red.  Same  interstitial  hemorrhages  as  in  the  preceding  case.  The  shedding 
of  epithelium  in  the  tube  is  much  more  evident.  The  cells  of  the  first  layer, 
and  a  great  part  of  the  spermatocytes,  remain  joined  to  the  wall.  Nuclei 
and  protoplasm  color  less  darkly. 

Glycogen  has  completely  disappeared. 

Fat  gets  out  from  the  seminiparous  cells,  to  localize  in  the  center  of  the 
tubes.  But  especially  one  may  find  an  adipose  excess  in  all  the  interstitial, 
intertubular,  subalbugineous,  pericanalicular,  lymphatic  spaces.  Sometimes 
fat  gets  out  at  the  same  time  by  the  excretory  canal,  and  by  the  interstitial 
tissue,  by  a  phenomenon  of  resorption  analogous  to  that  one  meets  around 
the  necrosed  foci. 

We  have  not  been  able  to  ascertain  the  stages  following  the  loss  of  the 
epithelium  and  the  abundant  interstitial  hemorrhages.  We  have  studied 
the  state  of  the  testicle  after  some  weeks  or  some  months. 

Dog  No.  37,  in  which  the  right  spermatic  artery  was  tied,  was  examined 
on  September  13th,  two  months  after  the  ligature.  The  testicle  was  small, 
soft,  and  it  had  a  normal  appearance.  It  bled  when  cut.  By  microscopical 
examination  it  looked  absolutely  normal,  with  numerous  spermatozoa. 
Glycogen  in  small  quantity  was  found.  The  results  obtained  on  dog  No.  1 
were  quite  similar. 


EXPERIMENTAL   TUBERCULOSIS    OF    TESTICLE. — ESMONET.  345 

Exp.  IV. — Dog  No.  1,  weigliing  12.2  kilograms. 

July  17th:  Ligature  of  both  spermatic  arteries. 

September  1 1th :  Both  testicles  are  easily  perceptible.  Their  consistency 
is  less  firm  than  normal. 

September  13th:  Ablation  of  the  left  testicle.  It  weighs  6.5  gr.  Its 
aspect  is  normal.  By  microscopical  examination  one  may  ascertain  sper- 
matogenesis, with  its  normal  evolution.  Spermatozoa  are  numerous.  In 
one  of  the  tubes  a  very  large  cell  is  found  ^\dth  a  crown  of  nuclei  at  the  per- 
iphery. This  cell  is  in  the  most  superficial  stratum  of  the  epitheUum  and  re- 
sembles the  coalescent  cellular  forms  found  in  seminal  catarrh.  A  few  grains 
of  glycogen. 

October  14th:  Ablation  of  the  right  testicle.  Weight  7.5  gm.  Its  aspect 
is  normal,  it  contains  numerous  spermatozoa.     Glycogen  in  great  quantity. 

It  follows,  from  the  comparison  of  the  results  obtained  by  the  ligature  of 
the  spermatic  artery  with  those  obtained  by  injection  of  cultures  or  of  poisons, 
that  to  the  first  belongs  the  extensive  hemorrhagic  effusions  and  the  pre- 
cocious shedding  of  the  seminal  epithelium. 

After  such  a  beginning  quickly  follows  the  reconstitution  of  the  epithelium 
and  the  clearing  of  the  interstitial  tissue.  Examination  of  the  testicle  made 
at  different  times,  after  two  months,  and  from  the  ninth  to  the  tenth  week, 
after  ligature  of  the  spermatic  artery,  shows  the  restitutio  ad  integrum  of  the 
seminal  epithehum,  in  which  the  spermatic  function  seems  completely  re- 
stored, and  where  one  may  even  ascertain  the  presence  of  two  indicators  of 
the  gland's  sexual  activity,  the  extra-tubular  and  intra-tubular  fat,  and  the 
glycogen  of  the  epithelium. 


TUBERCULOSIS  OF  THE  BREAST.* 
By  Wm.  L.  Rodman,  M.D.,  LL.D., 

Professor  of  Surgery  in  the  Medico-Chirurgical  College;  Surgeon  to  the  Medico-Chirurgical,  Presby- 
terian, Jewish,  and  Philadelphia  General  Hospitals. 


Virchow  did  not  include  tuberculosis  as  one  of  the  affections  to  which 
the  mammary  gland  was  liable.  Although  Sir  Astley  Cooper  and  Velpeau 
had  discussed  tuberculous  diseases  in  a  somewhat  vague  and  indefinite  way, 
it  was  not  until  1881  that  Dubar  made  a  careful,  systematic,  and  scientific 
classification  of  the  disease.  He  was  the  first  to  demonstrate  the  tubercle 
bacillus  in  connection  with  the  breast. 

Though  undoubtedly  rare,  tuberculosis  of  the  mammary  gland  is  more 
common  than  it  has  been  previously  thought  to  be.  In  fifteen  hundred 
cases  of  mammary  disease  admitted  to  St.  Bartholomew's  Hospital,  London, 
there  were  1.5  per  cent,  due  to  tuberculosis. 

Tuberculosis  of  the  breast  may  be  primary  or  secondary.  It  cannot 
be  stated  that  the  lesion  is  primary  unless  at  autopsy  a  careful  and  systema- 
tic examination  is  made  to  exclude  the  possibility  of  a  focus  elsewhere.  If 
no  such  focus  be  found,  it  is  fair  to  assume  that  the  disease  is  primary. 
When  primary,  infection  may  either  take  place  through  the  blood  or  directly 
from  without.  When  occurring  in  the  latter  way,  infection  may  take  place 
either  through  an  open  wound  or  through  the  galactophorous  ducts.  Ver- 
neuil  believed  strongly  in  the  latter  mode  of  infection.  Inasmuch  as  the 
lesions  are  more  pronounced  in  the  alveoli  than  in  the  ducts,  and,  further- 
more, as  the  ducts  themselves  are  not  more  diseased  at  their  exit  at  the 
nipple  than  in  the  substance  of  the  gland,  it  is  questionable  whether  infection 
through  the  duct  is  common.  If  infection  occurred  through  the  duct,  it 
is  reasonable  to  suppose  that  the  lesion  would  be  more  pronounced  at  the 
beginning  of  such  ducts  than  elsewhere.  Kitt,  who  has  made  a  thorough 
study  of  bovine  tuberculosis,  is  of  the  opinion  that  tuberculosis  of  the  udder 
is  nearly  always  of  hematogenous  origin. 

Secondary  tuberculosis  of  the  breast  may  result  from  the  extension  of 
the  disease  from  the  ribs  or  pleura,  or  be  carried  by  the  lymphatics  from 

*  This  article  came  to  hand  late.  Its  proper  place  is  in  the  proceedings  of  Tues- 
day, September  29th,  immediatly  after  the  article  of  Prof.  Sauerbruch. 

346 


TUBERCULOSIS   OF   THE    BREAST. — RODMAN,  347 

diseased  axillary  or  other  neighboring  lymphatic  glands,  or  through  the 
blood-current  from  a  focus  even  remotely  situated. 

It  has  been  fairly  well  estabhshed  that  the  disease  begins  within  the 
acini  rather  than  in  the  connective  tissue  of  the  breast. 

Etiology. — Mammary  tuberculosis  is  far  more  often  encountered  in 
females  than  in  males,  and  is  particularly  obnoxious  to  young  women.  Of 
thirty-two  cases  studied  by  Delbet,  there  were  eighteen  in  the  decennium 
from  twenty-five  to  tliirty-five.  Schley  was  of  the  opinion  that  it  occurred 
with  equal  frequency  in  the  third,  fourth,  and  fifth  decades.  Although 
more  often  found  in  young  women,  tuberculosis  may  be  found  at  any  time 
of  Ufe.     One  case  I  have  encountered  in  literature  in  a  woman  of  seventy. 

Heredity  exerts  little,  if  any,  influence.  Trauma  and  inflammatory 
affections,  by  lowering  the  vitality  of  the  breast,  predispose  it  to  subsequent 
tuberculosis.  Tuberculosis  in  other  parts  of  the  body  markedly  predisposes 
one  to  secondary  involvement  of  the  breast.  Mandry  found  tuberculosis 
elsewhere  in  one-half  of  the  cases  that  he  carefully  investigated. 

Pathology. — We  shall  not  consider  miliary  tuberculosis,  which  is  a  general 
process,  and  therefore  not  confined  to  the  breast.  There  are  both  discrete 
and  confluent  varieties.  In  the  former  there  are  isolated  tubercles  separated 
by  healthy  tissue.  These  tubercles  may  undergo  changes,  either  remaining 
isolated,  or  by  their  coalescence  forming  larger  masses,  this  constituting 
the  confluent  form  of  the  disease.  The  isolated  tubercles  vary  widely  in 
size,  some  being  smaller  than  a  pea,  others  as  large  as  a  hazelnut.  When 
caseation  and  liquefaction  occur,  abscesses  result. 

In  the  confluent  variety  a  swelling  of  considerable  proportions  results. 
It  is,  however,  not  sharply  limited,  being  ill-defined  and  irregular,  with 
bosselations  here  and  there.  If  cut  into  during  the  early  stages,  it  is  white 
or  grayish  in  color  and  rather  firm  in  consistency.  Later  on,  however,  the 
center  will  have  become  yellow  in  color,  although  the  periphery  may  still 
retain  the  original  appearance.  When  liquefaction  occurs,  the  so-called 
cold  abscess  of  Roux  results. 

Cases  of  tuberculosis  of  the  breast  coincident  with  carcinoma  have  been 
recorded.  In  one  of  four  cases  reported  the  symptoms  of  tuberculosis 
predominated  and  the  macroscopical  appearance  was  that  of  tuberculosis 
rather  than  carcinoma.  Microscopical  examination  demonstrated  carcinoma 
as  well.  I  have  seen  one  well-marked  instance  of  such  associated  disease, 
a  photograph  of  the  lesion  being  shown  in  my  book  on  diseases  of  the  breast. 
Of  two  such  cases  reported  by  A.  S.  Wartliin,  of  Ann  Arbor,  Michigan, 
tuberculosis  was  primary  in  one,  and  carcinoma  undoubtedly  the  primary 
lesion  in  the  other.  Pilliet  and  Piatot  reported  another  such  case  in  a  male 
aged  fifty-one. 

Rokitansky,  who  taught  that  tuberculosis  and  carcinoma  never  occur 


348  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

simultaneously,  aftei'^v'ard  acknowledged  his  error,  and  admitted  that  the 
two  diseases  were  infrequently  associated.  We  cannot  at  the  present  time 
say  whether  or  not  the  association  is  fortuitous,  or  whether  one  lesion  pre- 
disposes to  the  other.  It  is  not  difficult  to  understand  how  the  irritation 
produced  by  the  tubercles  might  easily  cause  abnormal  proliferation  of 
epithelial  cells  ending  in  cancer. 

Symptoms. — The  onset  of  the  disease  is  insidious,  except  when  it  occurs 
during  lactation,  when  it  is  of  more  rapid  growth.  It  may  last  for  years. 
Only  one  breast  is  affected,  there  being  no  case,  so  far  as  I  know,  where 
both  organs  were  involved. 

In  the  discrete  variety  indurated  areas  may  be  detected  here  and  there 
throughout  the  substance  of  the  gland,  but  separated  apparently  from  the 
surrounding  tissue.     In  other  cases  the  outUne  is  indefinite. 

The  skin  is  not  adherent  until  late  in  the  disease.  When  it  is,  fistulse 
soon  form.  Pain  is  a  rare  symptom  early  in  the  disease,  and  when  present 
does  not  exist  to  a  pronounced  extent.     It  may  be  severe  as  a  late  symptom. 

The  confluent  form  pursues  a  more  rapid  course,  fistula?  forming  early  in 
its  evolution.  A  mass  varying  in  size  from  a  hazelnut  to  an  orange,  of 
irregular  outline,  hard  or  soft,  is  found  usually  in  the  upper  and  outer  quad- 
rant. The  axillary  glands  are  early  involved,  rapidly  increase  in  size,  and 
may  suppurate.  It  is  to  be  noted  that  the  glands  do  not  fuse  and  become 
matted  together  as  in  carcinoma.  This  is  of  importance  as  a  differential 
sign. 

Diagnosis. — The  recognition  of  mammary  tuberculosis  may  at  times  be 
far  from  easy,  especially  if  the  case  presents  itself  before  there  is  destruction 
of  tissue.  When  fistula)  are  present,  together  with  enlarged  axillary  glands, 
there  should  be  little  difficulty  in  the  diagnosis.  Its  recognition  will  be 
easier  if  there  are  known  to  be  tuberculous  foci  elsewhere. 

The  disease  may  be  confounded  with  actinomycosis,  but  the  presence 
of  the  ray-fungus  in  the  latter  afTection  enables  a  positive  diagnosis  to  be 
made.  Tuberculosis  has  been  mistaken  for  carcinoma  and  vice  versa.  In 
cancer  the  skin  very  early  in  the  affection  becomes  adherent;  whereas  it  is 
a  late  symptom,  if  it  occurs  at  all,  in  tuberculosis.  In  cancer  the  axillary 
glands  may  enlarge  slowly,  are  harder,  and  become  fused  together,  which 
is  not  the  case  in  tuberculosis.  Tuberculous  disease  occurs  in  young  women 
more  generally.     Carcinoma  is  usually  found  after  forty. 

Prognosis. — In  primary  tuberculosis  the  prognosis  is  excellent.  In 
the  secondary  form  it  will  depend,  of  course,  upon  the  nature  and  extent  of 
the  primary  lesion.  Of  sixteen  patients  reported  by  Braendle,  of  the  Tubin- 
gen clinic,  fifteen  were  cured  by  operation  and  were  shown  to  be  well  one 
to  nineteen  years  afterward.  Three  of  these  patients  succumbed  to  phthisis 
subsequently.     There  was,  however,  no  local  recurrence. 


TUBERCULOSIS  OF  THE  BREAST. — RODMAN.  349 

Treatment. — ^Tuberculosis  of  the  breast  should  be  treated  by  excision 
of  a  wedge-shaped  portion  of  the  gland,  curetting  and  cauterizing  the  sinuses, 
or  by  amputation  of  the  breast,  according  to  the  extent  and  variety  of  the 
disease.  Where  the  process  seems  to  be  discrete  and  localized  in  a  definite 
portion  of  the  breast,  partial  resection  of  the  gland  is  a  warrantable  proce- 
dure. Where  a  large  part  of  the  breast  is  involved,  however,  nothing  short 
of  amputation  is  to  be  considered.  If  sinuses  are  not  too  numerous,  they 
may  be  curetted  and  cauterized.  In  one  of  my  cases,  a  girl  of  twenty-two, 
an  excellent  result  followed  plastic  resection  of  a  part  of  the  breast.  She 
was  entirely  cured  with  practically  no  resulting  deformity.  It  is  important, 
I  think,  that  the  mammary  gland  of  young  marriageable  women  should 
not  be  sacrificed  needlessly.  I  consider  it  necessary  that  the  axilla  should 
be  explored  in  all  cases,  and  if  enlarged  glands  are  found,  they  should  be 
removed.  An  excision  along  the  lower  border  of  the  breast,  after  Warren's 
method,  freely  exposes  both  the  entire  breast  and  the  axilla  to  view.  The 
scar  cannot  be  noticed  subsequently. 

In  cases  which  refuse  operation,  or  in  others  possibly  as  an  adjuvant  to 
it,  Wright's  bacterial  vaccines  should  be  used.  I  have  had  no  experience 
with  this  treatment,  but  its  value  in  other  forms  of  local  tuberculosis  war- 
rants its  employment  in  tuberculosis  of  the  breast. 

Bier's  treatment  may  also  be  given  a  fair  trial.  A  hemispherical  glass 
vessel,  somewhat  larger  than  the  breast  itself,  in  the  dome  of  which  there 
is  a  glass  nipple  attachment,  is  placed  over  the  breast.  A  rubber  tube  is 
placed  over  the  nipple  and,  a  suction  pump  being  attached,  sufficient  nega- 
tive pressure  is  made  to  cause  a  decided  hyperemia  of  the  skin.  This  is 
kept  up  for  five  minutes,  then  removed  for  five  minutes,  after  wliich  it  is 
reapplied.  This  is  repeated  for  tliirty  to  forty-five  minutes.  There  is  no 
reason  why  a  combination  of  Wright's  and  Bier's  treatments  may  not  be 
emplo3^ed,  for  in  this  way  the  opsonic  index  of  the  blood  may  be  relatively 
increased. 


Transactions 

of  the 


Sixth  International  Congress 
on  Tuberculosis. 

WASHINGTON,  SEPTEMBER  28  TO  OCTOBER  5,  1908. 


WITH  AN  ACCOUNT  AND  CATALOGUE  OF  THE  TUBERCULOSIS 

EXHIBITION, 

WASHINGTON.  SEPTEMBER  21  TO  OCTOBER  12,  1908. 


3n  ^ix  Volnmtsi. 

VOLUME   TWO. 


PROCEEDINGS  OF  SECTION  IV, 
Tuberculosis  in  Children — Etiology,  Prevention,  and  Treatment. 


Philadelphia : 

WILLIAM   F.   FELL  COMPANY 

1908. 


Officers  of  Section  IV. 


President: 
Dr.  Abraham  Jacobi. 

Honorary  Presidents: 
Dr.  Karl  Oscar  Medin,  Stockholm,    Dr.  Bertil  Buhre,  Stockholm, 
Prof.  R.  Lepine,  Lyon,  Prof.  Paul  Nobecourt,  Paris, 

M.  AuGUSTiN  Rey,  Paris,  Dr.  Carl  Hart,  Berlin, 

Dr.  Clemens  von  Pirquet,  Vienna,     Prof.  G.  Pannwitz,  Berlin. 
Dr.  Edouard  Rist,  Paris. 


Dr.  Isaac  A.  Abt, 
Dr.  S.  S.  Adams, 
Dr.  Wm.  D.  Booker, 
Dr.  H.  D.  Chapin, 
Dr.  John  M.  Dodson, 
Dr.  R.  G.  Freeman, 

Dr.  F.  FORCHHEIMER, 

Dr.  J.  P.  C.  Griffith, 
Dr.  S.  McC.  Hamill, 
Dr.  Alfred  Hand, 
Dr.  L.  Emmett  Holt, 
Dr.  Francis  B.  Huber, 

Dr.  David  Bovaird,  Jr., 


Vice-Presidents : 

Dr.  C.  G.  Jennings, 
Dr.  J.  H.  M.  Knox, 
Dr.  Henry  Koplik, 
Dr.  John  H.  Lowman, 
Dr.  H.  M.  McClanahan, 
Dr.  Charles  W.  Mitchell, 
Dr.  John  L.  Morse, 
Dr.  Wm.  P.  Northrup, 
Dr.  T.  M.  Rotch, 
Dr.  John  Ruhrah, 
Dr.  A.  H.  Wentworth, 
Dr.  Martha  Wollstein. 

Secretaries: 

Dr.  F.  S.  Churchill. 


VOL.  n — 12 


SECTION  IV. 

Tuberculosis    in    Children — Etiology,    Prevention, 

and  Treatment. 


FIRST  DAY. 

Monday,  September  28,  1908. 

PRESIDENT'S  ADDRESS.  FAMILY  HISTORY  OF  TUBERCULOUS  IN- 
FANTS. THE  VON  PIRQUET  REACTION.  TUBERCULOUS  LYM- 
PHATIC GLANDS.  THE  RELATION  OF  ACUTE  INFECTIONS  TO 
TUBERCULOSIS.     THE  OPSONIC  CONTENT  OF  BREAST-MILK. 


The  Section  was  called  to  order  by  the  President,  Dr.  Abraham  Jacobi, 
at  half  past  two  o'clock.  Honorary  Presidents  of  the  Section  were  elected  as 
follows : 

Dr.  Carl  Oscar  Medin,  Stockholm.         Dr.  Bertil  Buhre,  Stockholm. 
Dr.  R.  Lepine,  Lyons.  Dr.  Paul  Nobecourt,  Paris. 

M.  Augustin  Rey,  Paris.  Dr.  Carl  Hart,  Berlin. 

Dr.  Clemens  von  Pirquet,  Vienna.  Dr.  Gotthold  Pannwitz,  Berlin. 

Dr.  Edouard  Rist,  Paris. 

Before  taking  up  the  formal  program  the  President  addressed  the  Section 
as  follows: 


PRESIDENT'S  ADDRESS. 
By  Dr.  Abraham  Jacobi, 

New  York. 


America  has  seen,  during  a  few  decades,  many  large  and  influential 
meetings,  both  national  and  international.  They  were  dedicated  to  various 
interests,  scientific  and  commemorative,  warlike  and  peaceful.  The  grand 
exposition  and  congress  of  St.  Louis,  in  1904,  combined  in  twenty  sections 
whatever  appeared  to  a  thoughtful  and  energetic  central  committee  to  be 

355 


356  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

most  appropriate  in  bringing  together  the  best  thought  of  the  world.  Then, 
as  now,  great  men  reached  our  shores  over  the  ocean — which  has  become  a 
connecting  bridge,  after  having  proved  a  severing  gulf — to  exhibit  their 
own  and  others'  achievements,  and  succeeded  in  furnishing  a  comprehensive 
and  lifelike  exhibit  of  the  present  conditions  of  science  and  art  in  their 
influence  on  the  cultural  labor  of  mankind.  While  in  this  way  the  intellectual 
and  social  interests  of  the  world  were  displayed  and  fostered,  the  normal 
and  destructive  instincts  of  brute  man  were  also  studied  and  their  dire 
results  held  up  to  view,  in  the  peace  congresses  of  this  and  other  countries. 
Evidently  mankind  is  more  active  than  ever  in  the  attempt  to  be  rid  of  its 
savage  past  and  to  develop  a  humane  future  on  the  basis  of  the  impulses  of 
its  heart  and  the  dictates  of  its  brain. 

If  there  be  any  concourses  of  more  merit  and  endowed  with  more  benefi- 
cent influence  in  shaping  the  future  of  our  race  than  even  peace  congresses, 
it  is  the  series  of  congresses  on  hygiene  and  demography,  and  principally 
those  on  tuberculosis,  which  have  met  during  the  last  two  decades.  Repre- 
sentatives of  the  medical  professions  and  the  intellectual  lay  public  of  all 
civilized  nations  convened  with  a  sternly  expressed  demand  that  there  must 
be  an  end  to  the  hecatombs  of  victims  of  the  cruelest  enemy  of  our  race, 
which  cannot  be  combated  except  by  an  aggressive  movement  of  the  whole 
line.  Altogether,  the  fight  against  infectious  and  contagious  diseases  is  no 
longer  a  strictly  medical  matter.  What  our  active  practitioners  and  our 
laboratory  experts  could  do  they  have  accomplished.  The  nature  of  anthrax, 
of  diphtheria,  scarlet  fever,  and  typhoid  fever  have  been  recognized  and 
proclaimed,  urbi  et  orbi,  and  preventives  have  been  found  and  advised. 
If  governments  and  their  employees  have  in  many  cases,  and  not  least  in  our 
country,  neglected  our  warnings  and  active  measures,  we,  the  physicians, 
have  mourned  and  our  fellow-citizens  have  suffered.  For,  though  we 
have  the  knowledge  of  the  causes  of  typhoid  fever  at  our  fingers'  ends, 
vigorous  men,  before  they  ever  saw  an  enemy,  have  died  in  untold  numbers 
in  camps;  and  towns  and  country  have  been  devastated  by  it,  though  it 
belongs  to  a  class  of  easily  prevented  epidemics.  Hundreds  of  endemics 
and  epidemics  of  scarlet  fever  and  diphtheria  have  followed  the  track  of 
infected  foods,  and  hundreds  of  thousands  of  promising  infants  and  children 
are  swept  away  annually  by  decomposed  or  infected  milk.  Tuberculosis 
has  proved  the  deadliest  and  most  obstinate  enemy  of  them  all.  Its  onset 
is  insidious,  its  course  frequently  not  suspected  or  watched;  its  invasion  not 
prevented,  on  account  of  the  neglect  of  mucous  membranes;  its  development 
insured  by  depressed  vitality;  its  curability  ignored,  and  its  fatal  termination 
more  feared  than  palliated. 

This  Fourth  [Section  of  this  Congress,  dedicated,  as  it  is,  to  the  etiology, 
prevention,  and  treatment  of  tuberculosis  in  children,  does  not  discuss  the 


president's   address. — JACOBI.  357 

mooted  question  of  whether  pediatrics  deserves  a  place  among  the  special- 
ties in  medical  practice.  Your  problems  are  more  direct.  Is  the  tubercu- 
losis of  infancy  and  children  exactly  like  that  of  advanced  years?  What  is 
its  frequency?  Are  most  cases  of  tuberculosis  of  the  adult  preformed  in 
the  child,  as  it  has  been  claimed?  Does  tuberculosis  depend  on  milk  alone, 
or  is  it  so  in  the  majority  of  cases?  Or  has  milk- feeding  little  or  nothing 
to  do  with  its  origin?  What  is  the  difference  between  bovine  and  human 
tuberculosis?  How  is  milk  to  be  treated?  Is  it  to  be  administered  raw, 
pasteurized,  scalded,  sterilized,  pure,  or  diluted,  or  mixed?  What  has  the 
udder  or  the  mamma  to  do  with  it?  These  and  many  other  questions  are 
placed  before  you  in  the  syllabus  I  distributed  a  year  ago.  Besides,  what  is, 
after  all — in  connection  with  the  question  of  vitality  and  power  of  resistance 
and  of  predisposition — what  is  infancy  and  childhood?  Their  boundary- 
lines  vary  with  different  points  of  view.  The  law  of  our  land  terminates 
childhood  with  the  sixteenth  year.  Others  look  for  puberty  as  the  closing 
period.  Our  Thomas  Rotch  has  taught  us  not  to  count  years,  but  the 
development  of  the  osseous  system,  in  deciding  the  question  of  maturity 
or  fitness  for  labor,  and  others  are  guided  by  the  degree  of  the  retardation 
or  advancement  in  the  evolution  of  other  organs.  This  much  is  certain, 
that  no  whimsical  legal  decision  will  determine  physiological  or  pathological 
questions,  but  alone  medical  knowledge  and  the  physician,  who  should  be 
consulted  in  every  doubtful  case. 

The  relation  of  the  physician  to  the  treatment  of  tuberculosis  is  twofold. 
As  the  medical  adviser  of  the  individual  patient,  he  looks  out  for  his  com- 
fort, advises  him  in  regard  to  his  diet  and  other  hygiene,  selects  a  sanatorium, 
counsels  change  of  occupation,  and  utilizes  other  therapeutic  measures. 
Time  and  again  he  may  demonstrate  that  the  administration  of  drugs  is  not 
obsolete  or  powerless.  There  are  many  symptoms  to  be  relieved  or  removed, 
the  power  of  vital  resistance  to  be  increased,  the  circulation  to  be  strength- 
ened, digestion  stimulated,  nutrition  improved  by  hydropathy  and  by  medi- 
cation with  arsenic,,  digitalis,  guaiacol  or  bone-marrow.  A  great  many  mis- 
takes are  being  made  by  relying  on  one-sided  fashionable  methods  only,  be 
they  rational  in  themselves  or  only  temporary  fads.  Rest  and  food,  and 
air  and  change  of  air,  are  ever  so  man)'  steps  in  the  right  direction.  One, 
however,  must  not  exclude  the  other,  and  the  loud  pronunciamentos  against 
the  materia  medica  are  the  results  of  prejudice  and  ignorance.  It  is  true 
that  the  voices  protesting  against  the  assistance  offered  by  the  pharmacopeia 
are  impetuous,  aye,  stentorian;  but,  two  thousand  years  ago,  our  old  friend 
Plutarch  taught  us  that  all  hollow  things  are  sonorous. 

In  this  way  many  are  saved.  It  is  true  that,  while  what  we  accomplish 
is  frequently  the  restoration  of  perfect  health,  in  too  numerous  cases  life  only, 
without  health,  is  preserved.     But  the  invalid  has  a  right  to  life,  and  to 


358  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

command  our  efforts  to  save  and  to  invigorate  him.  It  is  not  our  fault 
when  the  average  vigor  of  human  society  is  undermined  by  the  accumulation 
of  numberless  invalids  kept  alive.  In  such  situations  the  subjects  of  our 
exertions  are  sick  individuals  who  insist  upon  salvation  from  death,  and 
demand  that  their  lives  be  prolonged,  though  they  be  less  than  normally 
competent.  In  that  way  we  still  add  to  the  human  capital  and  to 
economic  wealth,  while  other  forces  actually  reduce  and  impair  it.  It  is 
characteristic  for  misanthropic  critics  to  blame  us  for  preserving  inferior 
individuals,  but  not  to  object  to  wholesale  destruction  of  strong  men. 
For  the  strenuous  foolhardiness  which  still  sees  virtue  and  happiness  in 
warlike  enterprises  forgets  that  by  war  the  flower  of  the  land's  men,  and 
not  weaklings,  are  killed  or  rendered  invalid  or  demoralized,  and  that 
the  lower  stratum  of  vigor  remains  behind  to  live  and  to  multiply  and  to 
transmit  their  own  diseases  or  physical  inferiority  or  predispositions. 
No  infectious  disease  ever  left  the  people  in  as  low  a  physical,  moral,  and 
economic  condition  as  does  a  war  of  equal  duration  or  ferocity. 

At  best  the  recovery  of  the  tuberculous  individual  is  difficult,  and  too 
often  doubtful.  In  common  life  it  is  the  family  physician  who  knows  the 
physical  traits  of  his  wards  and  is  in  a  position  to  employ  the  means  of  pre- 
vention at  his  disposal.  The  time  should  come  very  soon  when  the  specialis- 
tic  fad,  which  has  invaded  and  controls  the  public  even  more  than  our  pro- 
fession, will  make  way  for  the  renewed  recognition  of  the  family  physician 
as  the  truest  friend  and  the  most  meritorious  adviser.  Too  often,  when  the 
tuberculosis  specialist  is  consulted,  the  preventive  and  curative  measures 
of  the  family  practitioner,  who  was  not  consulted,  are  no  longer  within  reach. 
What  the  latter  is  doing  for  the  individual  or  for  the  family,  medical  science 
and  the  profession  at  large  have  been  and  are  doing  for  the  sanitary  conditions 
of  the  public  at  large  and  the  community,  through  well-directed  literature, 
through  boards  of  health,  and  through  legislation.  This  very  Congress  has 
reserved  a  whole  section  to  the  consideration  of  State  and  municipal  control 
of  tuberculosis,  and  of  laws  and  ordinances  relating  to  it.  The  time  is 
approaching  when  the  people  will  insist  upon  having  health  safeguarded 
by  the  public  recognition  of  its  claims.  We  have  in  this  country  a  cabinet 
with  special  members  for  law,  for  war,  for  the  navy,  for  foreign  politics,  for 
internal  political  and  economic  improvements.  We  have  a  special  depart- 
ment for  agriculture,  which  supplies  the  people  with  rare  and  common  seeds, 
and  prevents  and  cures  the  diseases  of  their  cattle.  We  even  begin  to  make 
an  end  to  our  dereliction  in  allowing  our  forests  to  be  burned  or  stolen. 
We  have,  however,  no  central  representation  of  the  forces  that  make  for 
the  physical  welfare  of  the  people,  and  no  United  States  board  of  health 
in  the  advisory  cabinet  of  the  first  employee  of  the  nation.  That  is  why 
the  people,  in  their  democratic  and  self-determining  methods,  are  gathering 


president's   address. — JACOBI.  359 

in  societies,  attempting  and  attaining  what  in  many  other  countries  it  takes 
the  powers  of  the  governments  to  accompUsh.  That  is  why  a  congress 
Uke  this  invites  the  pubUc  at  large,  and  the  national  and  foreign  govern- 
ments, to  share  the  labors  and  responsibilities  of  the  medical  professions  of  the 
world.  Nothing  proves  to  better  advantage  the  interdependence  of  the 
several  parts  of  the  social  organism,  or  the  absolute  impossibility  of  one  man, 
or  one  class  of  men,  passing  a  hermit  life  and  still  prove  useful.  The  indivi- 
dual physician  deteriorates  when  in  solitude.  His  very  studies,  his  work, 
require  friction  and  cooperation  and  mutual  instruction.  The  intercourse 
with  his  peers  corrects  his  ignorance,  which,  as  the  sick  around  him  have  to 
suffer  from  it  more  than  he,  is  sinful.  No  progress  is  ever  evolved  from 
castes,  classes,  or  ruts.  That  is  why  the  wondrous  civilization  of  Asia 
came  to  a  standstill  at  an  early  period.  No  single  isolated  source  of 
instruction  is  prolific.  That  is  why  medicine  cannot  be  learned  from 
mere  books,  any  more  than  chemistry  or  politics.  Indeed,  in  hermit  life 
there  is  such  a  thing  as  a  primeval  forest  of  ignorance  and  helplessness, 
inextricable  and  aimless. 

That  is  why  so  much  can  be  accomplished  by  cooperation  with  the  public 
at  large,  according  to  such  methods  as  this  Congress  contemplates  and  provides. 
Indeed,  medicine  must  become  a  popular  science;  not  the  cheap  medicine  of  the 
sensational  penny-a-liner,  but  the  fertilizing  knowledge  of  basic  truths 
in  physiology  and  applied  hygiene.  In  this  new  century  universal  ignorance 
of  any  people  or  any  race,  even  the  white  race,  should  be  esteemed  an  intolerable 
scandal,  as  it  surely  leads  to  poverty  and  anarchy.  Do  not  tell  me  that  it  has 
been  said  that  half  knowledge  is  the  most  detrimental  thing.  It  is  not 
half  knowledge  that  engenders  superstition,  and  lynching,  and  sectarianism, 
and  faith  cures — they  originate  from  the  same  depth  of  darkness — it  is  total 
ignorance.  As  long  as  medical  science  will  not  enlighten  the  masses  with  its 
fundamental  principles,  it  has  failed  in  its  most  vital  vocation.  The  simple 
facts  of  medicine  should  be  taught  in  intelligible  language  in  schools,  from 
platforms,  the  pulpits,  and  last,  by  no  means  least,  in  newspapers.  I  know 
of  none  of  the  latter  which  has  followed  the  advice  I  gave  a  few  of  them 
a  score  of  years  ago,  and  since,  namely,  to  give  the  first  and  best-paid  place 
on  their  editorial  staff  to  an  all-round  medical  man,  with  no  duty  in  life 
except  to  teach  the  millions  of  readers  the  axioms  of  physiology  and  hygiene, 
and  their  application  to  practical  every-day  life;  and  no  longer  to  rely  on 
the  haphazard  opinions  expressed  in  interviews  by  medical  men  who  are 
given  no  time  to  think,  or  who  are  waiting  for  an  opportunity  to  advertise 
themselves. 

The  unity  of  science  has  been  preached  this  half  century.  There  must 
be  unity  of  science  and  the  nation's  practice.  Men  and  women  must  learn 
that  hygiene  is  no  cure,  nor  is  mere  disinfection ;  that  it  means  prevention, 


360  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

prevention  in  the  life  of  the  individual,  the  town,  the  nation,  mankind. 
We  trust  it  may  lead  to  a  realization  of  the  fact  that  a  permanent  health  of 
the  people  at  large  cannot  be  fully  attained  except  by  fundamental  social 
and  political  alterations.  As  these  are  far  distant,  the  changes  we  should 
wish  to  enforce  cannot  be  otherwise  than  gradual.  Now,  our  successes 
in  exterminating  tuberculosis,  though  they  have  been  marked,  have  been 
slow.  In  order  to  succeed  fully,  our  work  must  be  both  individual  and 
collective.  Still,  neither  you  nor  I  may  live  to  see  complete  consummation. 
It  may  be,  however,  that  some  of  you  have  read  the  epitaph  on  Charles 
Wesley's  tomb  in  Westminster:  "God  buries  his  workmen  but  continues 
his  work."  Thus  as  there  were  workmen  in  our  field  before  you  and  me, 
let  us  prepare  the  soil  still  better  for  those  who  will  come  after  us,  and  still 
diminish  the  distance  between  the  ideal  and  its  realization.  We  doctors 
shall  not  find  that  very  difficult,  when  we  remember  that  our  father  Hippo- 
crates identified  the  love  of  mankind  with  the  love  of  our  vocation.  Both 
will  aid  us  in  assisting  the  advent  of  that  era  of  therapy  which  is  dawning, 
and  promises  cures  and  preventions  in  physical,  political,  and  social  con- 
ditions, and  to  help  us  become  active  citizens,  both  of  the  present  and  of  the 
inevitable  happier  future. 


TUBERCULOSIS   IN  INFANTS: 

AN  ANALYSIS  OF  131  HOSPITAL  CASES  AS  REGARDS    FAMILY 

HISTORY  AND  PHYSICAL  SIGNS,  WITH  RE:\IARKS 

UPON  PREVENTION  AND  TREATMENT. 

By  Linn^us  Edford  La  Fetra,  M.D., 

New  York. 


The  material  comprises  73  cases  of  proved  pulmonary  tuberculosis  and 
58  cases  of  proved  meningeal  tuberculosis.  The  cases  were  observed  by 
the  different  attending  physicians  at  the  Babies'  Hospital,  New  York  city, 
between  October  1,  1905,  and  July  15,  1908,  and  the  records  have  been  used 
since  by  the  courtesy  of  Dr.  L.  Emmett  Holt,  the  senior  attending  physician. 
Credit  is  due  also  to  Dr.  Josephine  Hemenway,  the  resident  physician,  and 
Dr.  Martha  Wollstein,  the  pathologist,  for  their  care  and  diligence  in  the 
bacteriological  study  of  the  cases. 

The  majority  of  the  patients  were  under  twelve  months  of  age  and  none 
over  three  years.  The  youngest  pulmonary  case  was  two  and  one-half 
months;  the  youngest  meningeal  case  was  four  months  old. 

The  pulmonary  cases,  73  in  number,  represented  2^  per  cent,  of  the  2825 
cases  admitted  during  the  period.  They  were  proved  to  be  tuberculosis 
by  finding  tubercle  bacilli  in  the  sputum  in  53  cases,  in  the  pus  aspirated 
from  the  lung  in  one  case,  by  necropsy  alone  in  1 1  cases,  and  by  both  necropsy 
and  bacilli  in  the  sputum  in  8  cases.  It  is  noteworthy  that  bacilli  were 
obtained  in  the  sputum  examinations  of  the  infants  in  so  large  a  proportion 
of  the  cases,  namely,  over  70  per  cent.  The  sputum  is  obtained  either  by 
passing  a  catheter  into  the  esophagus,  or  by  tickling  the  epiglottis  with  a 
piece  of  dry  gauze,  held  in  a  curved  clamp. 

The  meningeal  cases,  58  in  number,  represented  nearly  2^  per  cent,  of 
the  2447  patients  admitted  during  the  period.  They  were  proved  tuber- 
culous by  tubercle  bacilli  being  found  in  the  spinal  fluid  in  52  cases,  by 
necropsy  alone  in  1  case,  and  by  both  necropsy  and  bacilli  in  the  spinal 
fluid  in  5  cases.  In  only  one  case  were  no  bacilli  found  in  the  lumbar 
puncture  fluid.  In  this  case  at  necropsy  the  brain  showed  miliary  tuber- 
culosis. 

361 


362  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

TABLE  I.— TUBERCULOSIS  IN  INFANTS 

(Babies'  Hospital,  New  York  City). 

73  Cases  of  Pulmonary  Tuberculosis 

proved  by  tubercle  bacilli  in  sputum 61  cases 

proved  by  (necropsy  also  in  8). 

proved  by  bacilli  in  aspirated  pus 1  case 

proved  by  necropsy  alone 11  cases 

73  cases 
58  Cases  of  Meningitis  Tuberculosa 

proved  by  bacilli  in  spinal  fluid 57  cases 

proved  by  (necropsy  also  in  5). 

proved  by  necropsy  alone 1  case 

58  cases 

In  connection  with  the  hunt  for  tubercle  bacilli  in  the  spinal  fluid  search 
was  made  for  bacilli  in  the  sputum  of  all  but  one  of  these  meningeal  cases. 
The  results  are  very  striking,  for  tubercle  bacilli  were  found  in  the  sputum 
of  33  of  the  57  cases.  In  8  of  these  meningeal  cases  bacilh  were  found  in 
the  sputum  when  there  were  no  symptoms  or  physical  signs  of  any  chest 
involvement.  There  were  evidences  of  pulmonary  trouble  in  28  cases — 
bronchitis  20  times  and  consolidation  8  times.  To  these  must  be  added 
the  8  cases  of  bacilli  in  the  sputum,  making  altogether  26  out  of  the  58 
meningeal  tuberculosis  patients  that  had  pulmonary  invasion. 

TABLE  II.— TUBERCULOSIS  IN  INFANTS 

(Babies'  Hospital,  New  York  City). 

In  58  Cases  of  Meningeal  Tuberculosis  the  lungs 

Were  affected  in 36  cases 

No  physical  signs  in 8 

Signs  of  bronchitis  in 20 

Signs  of  consolidation  in 8 

Tubercle  bacilli  in  sputum 33 

Tubercle  bacilli  in  sputum  without  physical  signs  in  chest.  .  8 

Etiology;  Family  History. — As  regards  etiology,  the  mother,  father,  or 
some  one  else  in  close  contact  with  the  patient  was  found  to  have  suffered 
from  tuberculosis — almost  invariably  pulmonary — in  over  40  per  cent,  of 
the  meningeal  cases.  The  exact  figures  are  as  follows:  Among  the  73 
pulmonary  cases  there  was  tuberculosis,  generally  of  the  lungs,  in  the 
famiUes  as  follows:  father,  12  times;  mother,  13  times;  uncle  or  aunt,  2; 
other  relatives,  2;  nurse  or  friend,  2;  tuberculosis  in  the  room,  1; — a  total 
of  32  times  in  73  families,  or  over  40  per  cent. 

Among  the  meningeal  cases  there  was  open  tuberculosis  in  the  families 
as  follows:  father,  11  times;  mother,  2;  uncle  or  aunt,  2;  other  relative,  3; 
nurse  or  friend,  3; — a  total  of  21  times  in  58  families,  or  nearly  40  per  cent. 
The  father  was  the  source  of  infection  more  frequently  than  one  would  have 


TUBERCULOSIS   IN   INFANTS. — LA   FETRA,  363 

expected,  namely,  in  23  of  the  53  cases  in  which  the  probable  source  could 
be  traced.  Of  particular  importance,  because  avoidable,  are  those  cases  in 
which  an  invalid  friend,  male  or  female,  was  permitted  (having  nothing 
more  important  to  do)  to  take  care  of  the  baby  or  carry  it  outdoors  for  an 
airing  while  the  mother  attended  to  her  housework,  and  those  cases  in  which 
such  persons  borrowed  the  baby  to  play  with,  and  those  in  which  the  family 
harbored  a  boarder  with  a  chronic  cough. 

TABLE  III.— TUBERCULOSIS  IN  YOUNG  INFANTS— FAMILY  HISTORY. 

Tdberculosis  in:  73  Pulmonary.     58  Meningeal.         Total,  131 

Father 12  11  23 

Mother 13  2  '                    15 

Uncle  or  Aunt 2  2  4 

Other  Relative 2  3  5 

Friend  or  Nurse 2  3  5 

Room  infected 1  —  1 

Totals 32  21  53 

Percentage 43.8  36.2  40.4 

It  was  impossible  to  investigate  the  cow's  milk  used  by  those  artificially 
fed;  but  it  is  significant  that  there  were  only  two  cases  of  peritoneal  tubercu- 
losis, and  no  case  of  tuberculous  enteritis,  in  the  series.  Moreover,  the 
tenement  population  of  New  York  almost  invariably  boils  the  milk  as 
soon  as  it  reaches  the  home. 

Diagnosis;  Physical  Signs. — ^The  diagnosis  of  tuberculosis  of  the  lungs 
in  these  infants  by  physical  examination  of  the  chest  is  impossible  in  a 
large  proportion  of  the  cases.  Some  give  no  signs  at  all,  many  present 
simply  the  generalized  rales  of  an  ordinary  bronchitis,  while  others  give 
signs  of  lobar  or  bronchopneumonia;  only  a  few  present  evidences  of  cavity 
or  of  consolidation  with  adhesions.  When  consolidation  is  present,  its 
location  is  not  characteristic.  Taking  the  73  pulmonary  cases  and  adding 
to  them  the  36  cases  of  meningeal  tuberculosis  in  which  the  lungs  were 
involved,  there  was  a  total  of  109  cases.  The  subjoined  table  shows  the 
findings: 

TABLE  IV.— PHYSICAL  EXAMINATION  OF  THE  CHEST. 

109  Cases  of  Tuberculosis  of  Lungs — 73  of  pulmonary  proper,  and 
36  of  meningeal  tuberculosis  in  which  lungs  also  affected: 

No  physical  signs 11  cases 

Signs  of  general  bronchitis 46     " 

Signs  of  bronchopneumonia  or  of  consolidation  and  bron- 
chitis      15     " 

Signs  of  consolidation 56 

Signs  of  cavity 5 

Total 133  cases 

Counted  twice 24 

109  cases 


364  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

The  location  of  the  consolidation  or  the  cavity  was  anywhere  from  the 
apex  to  the  lower  lobe  in  either  lung.  Involvement  of  the  right  lung, 
however,  and  especially  its  upper  and  middle  lobe,  was  twice  as  frequent 
as  of  the  left  lung;  thus  there  were  35  cases  in  which  the  right  lung  was 
affected  to  18  of  the  left  lung.  When  present,  localized  signs  in  the  nipple 
region  of  either  lung,  especially  the  right,  are  very  suspicious  of  tuberculosis. 
It  is  to  be  emphasized,  however,  that  there  were  57  of  these  109  cases  in 
which  there  were  either  no  signs  at  all  or  only  those  of  general  bronchitis. 

TABLE  v.— LOCATION  OF  CONSOLIDATION  IN  FIFTY  CASES. 
Right  Chest.  Left  Chest.  Total 

5 Apex 3  8 

4 Upper  Lobe 5  9 

9  (plus  6) Middle  Lobe —  — 

13 Lower  Lobe 7  20 

7 More  than  one  Lobe 6  13 

38 Total.... 21  59 

Counted  twice 9 

50 
Location  of  Cavity  (Five  Cases). 
Right  Chest.  Left  Chest.  Total. 

2 Apex —  — 

— Upper  Lobe 1  — 

1 Lower  Lobe 1  — 

3  2  5 

This  demonstrates  the  inadequacy  of  the  chest  examination  by  percussion 
and  auscultation,  and  shows  the  need  of  the  a;-ray  examination  and  of  the 
newer  tuberculin  tests.  Dr.  Holt  will,  in  the  paper  he  presents,  give  the 
results  of  the  ophthalmic  and  skin  reactions  made  in  the  Babies'  Hospital. 

For  an  absolutely  positive  diagnosis  of  pulmonary  tuberculosis  in  an 
infant  suffering  from  a  persistent  hacking  cough, — whether  poorly  nourished 
or  not, — one  must  either  find  the  bacilli  in  the  sputum  or  see  the  lesion  at 
necropsy;  but  the  new  tuberculin  reactions  of  von  Pirquet,  of  Calmette  and 
Moro,  when  positive  in  these  young  subjects,  are  almost  as  rehable.  For 
the  negative  side  more  can  be  said.  If  no  bacilli  can  be  found  in  the  sputum 
after  repeated  careful  search,  and  if  the  skin  test  is  also  negative,  one  can 
feel  safe  in  excluding  tuberculosis  of  the  lungs,  no  matter  what  the  signs  in 
the  chest  may  be.  I  have  repeatedly  observed  consolidations  in  older  children 
and  localized  rales  in  younger  ones,  which  later  have  cleared  up  rapidly 
and  entirely.  From  the  physical  signs  alone  any  one  would  have  asserted 
that  they  were  tuberculous. 

For  a  positive  diagnosis  of  meningeal  tuberculosis  the  bacilli  should  be 
found  in  the  spinal  fluid  or  the  tubercles  seen  on  the  meninges  at  necropsy. 
The  newer  skin  tests  are  of  no  value  except  in  the  last  stages  of  the  disease. 


TUBERCULOSIS   IN   INFANTS. — LA   F^TRA.  365 

Results;  Prognosis. — The  58  meningeal  cases  all  died  in  the  hospital. 
Of  the  73  pulmonary  cases,  31  died  in  the  hospital,  26  were  discharged  unim- 
proved, one  was  cured,  and  the  remaining  15  improved.  It  is  known  that 
there  were  at  least  two  deaths  among  those  discharged,  and  that  of  the 
remaining  39,  three  are  apparently  well  and  a  fourth  is  recovering  in  a  sana- 
torium for  tuberculosis.  This  was  a  patient  ten  months  old  at  the  time 
the  tuberculous  bronchitis  was  discovered;  he  is  now  two  years  old. 

The  others  that  recovered  entirely  are  as  follows: 

A  two-year-old — ^two  years  after  discharge  he  seems  well. 

An  eighteen-months-old — eighteen  months  after  discharge  he  seems  well. 

A  twelve-months-old  Chinese  baby — ^he  had  consolidation  at  the  right 
lower  lobe  and  general  bronchitis  with  abundant  tubercle  bacilli.  One 
year  after  discharge  he  was  "recovering  in  a  Chinese  tenement-house." 

Among  the  patients  treated  in  the  hospital  at  the  same  time,  and  without 
much  doubt  belonging  in  the  same  class  of  pulmonary  tuberculosis, — 
though  this  was  not  proved  by  finding  bacilU  in  the  sputum, — were  6  other 
cases.  This  was  before  the  time  of  the  newer  skin  tuberculin  reactions; 
but  one  gave  a  positive  injection  reaction.  In  5  of  their  families  tubercu- 
losis was  present.  Of  these  6  cases,  3  patients  died  soon  after  leaving  the 
hospital  and  3  recovered  completely.  The  important  point  is  that  tubercu- 
losis of  the  lungs  in  infants,  though  a  very  dangerous  affection,  is  not  to  be 
regarded  as  hopeless,  even  when  the  patients  live  in  an  unfavorable  environ- 
ment. The  recovery  of  these  4  cases  of  proved  and  3  cases  of  most  probable 
tuberculosis  of  the  lungs  is  a  strong  argument  for  segregation  and  active 
treatment. 

Had  isolation  from  the  known  source  of  infection  been  practised  in  these 
cases,  the  series  would  have  been  reduced  from  131  to  94 — a  reduction  of 
morbidity  and  mortality  of  over  33  per  cent.  In  prophylaxis  it  would  cer- 
tainly seem  desirable  that  tuberculous  persons  should  not  have  children — per- 
haps that  they  should  not  marry.  Before  the  birth  of  a  child  the  father  and 
mother  should  be  warned  that  tuberculosis  is  conveyed  directly  to  the  off- 
spring by  close  contact,  such  as  fondUng,  kissing,  and  especially  by  nursing 
a  tuberculous  mother.  In  addition  to  all  the  usual  hygienic  measures,  iso- 
lation from  the  afflicted  person  should  be  maintained  as  fully  as  possible. 
The  baby  should  not  be  allowed  to  creep  on  the  floors,  and  these  should  be 
covered  only  by  washable  rugs.  Milk  from  untested  cattle  should  be  steril- 
ized and  the  diet  carefully  adapted  to  the  baby's  needs. 

All  children  of  tuberculous  famiUes  should  be  periodically  examined,  not 
only  for  physical  signs,  but  also  for  the  reaction  to  tuberculin  by  either  the 
skin  or  the  eye  tests.  Suspicious  subjects  should  at  once  be  sent  to  a  woods 
school  or  country  sanatorium,  or  if  the  patient  cannot  go  away,  the  fresh-air 
treatment  should  be  undertaken  at  home  by  window  tents,  roof  sleeping,  etc. 


366  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

Persistent  coughs  in  infants  should  be  vigorously  treated  lest  the  lungs 
become  hopelessly  infected  or  tuberculous  meningitis  supervene. 


Tuberculosis  en  los  Ninos,   un  Analisis  de    130   Casos  en  el  Hospital 
con  Relacion  a  la  Etiologia,  y  el  Diagnostico,  la  Prevencion 
y  el  Tratamiento. — (La  Fetra.) 

Los  pacientes  fueron  menores  de  tres  afios  de  edad  y  la  mayor  parte 
menores  de  un  ano  de  edad.  La  madre,  el  padre  6  algun  otro  en  contacto 
Intimo  con  el  paciente  se  sabe  haber  padecido  de  tuberculosis,  casi  invariable 
la  infeccion  fue  pulmonar,  50  por  ciento,  y  en  mas  de  una  tercera  parte  de 
los  casos  tuberculosis  de  las  meninges.  Entre  los  casos  de  tuberculosis  de 
las  meninges  mas  de  la  mitad  han  tenido  tuberculosis  pulmonar. 

En  la  mayor  parte  de  los  casos  de  afeccion  pulmonar,  es  casi  imposible 
hacer  el  diagnostico  de  la  tuberculosis  por  medio  del  examen  del  pecho. 
Algunos  casos  no  presentan  signos,  en  otros  los  sintomas  son  generalizados, 
mientras  que  otros  presentan  signos  de  bronco-neumonla  6  de  neumonia 
lobular;  muy  pocos  presentan  signos  caracteristicos  tales  como  consolida- 
cion  con  adhesion  6  de  cavidad.  La  localizacion  de  la  consolidacion  no  es 
caracteristica.  Para  un  diagnostico  positivo  uno  debe  de  encontrar  el 
bacilo  en  el  esputo  6  ver  el  caracter  de  las  lesiones.  Una  reaccion  cut- 
anea en  estas  personas  jovenes  es  sinembargo  la  mas  cierta.  Si  el  examen 
del  esputo  y  la  reaccion  cutanea  son  negativos,  uno  puede  menospreciar  los 
sintomas  del  pecho  y  eliminar  la  tuberculosis  en  el  diagnostico.  De  los  73 
casos  de  tuberculosis  pulmonar,  34  fallecieron,  29  no  mostraron  mejoria 
alguna  y  10  mejoraron.  Cuatro  pacientes,  segun  parece,  se  aliviaron  com- 
pletamente,  en  estos  no  se  encontraron  los  sfntomas  de  los  pulmones  despues 
de  uno  6  dos  afios  de  haber  dejado  el   hospital. 

Profilacticamente,  el  padre  y  la  madre,  en  una  familia  tuberculosa, 
antes  del  nacimiento  del  niiio,  deben  ser  instruidos  sobre  el  peligro  de  la 
infeccion  del  nino  por  medio  de  la  leche  de  la  madre  y  los  besos.  Aisla- 
miento  del  las  personas  afectadas  en  tanto  como  sea  posible,  prevenir  al 
nino  de  gatear  en  el  suelo,  prohibir  el  uso  de  alfombras  que  no  se  puedan 
lavar,  esto  y  otras  medidas  higiencias  deben  ser  obligatorias.  Esterili- 
zacion  de  la  leche.  Los  ninos  de  padres  tuberculosos  deben  ser  examina- 
dos,  en  cuanto  a  la  reaccion  cutanea,  perodicamente.  Casos  sospechosos 
deben  ponerse  bajo  un  tratamiento  activo,  si  posible  en  casas  6  escuelas  de 
campo.  La  tos  persistente  en  los  ninos  debe  ser  tratada  activamente  para 
evitar  la  meningitis  tuberculosa. 


TUBERCULOSIS  IN  CHILDREN, 

PARTICULARLY    WITH    REFERENCE    TO    TUBERCULOSIS   OF 

LYMPHATIC  GLANDS,   AND   ITS   I^^IPORTANCE  IN  THE 

INVASION  AND  DISSEMINATION  OF  THE  DISEASE. 

By  Theodore  Shennan,  M.D., 

Edinburgh. 


The  tables  presented  in  this  paper  epitomize  the  results  of  an  investiga- 
tion of  the  post-mortem  records  of  the  Royal  Edinburgh  Hospital  for  Sick 
Children,  in  the  case  of  children  dying  from  tuberculosis  while  in-patients  of 
that  hospital. 

The  period  covered  by  the  records  dates  from  February,  1883,  to  April, 
1904,  a  little  over  twenty-one  years.  The  successive  pathologists  respon- 
sible for  the  conduct  of  the  examinations  during  that  time  were  Sims 
Woodhead,  Alexander  Bruce,  David  Welsh,  myself,  and  Stuart  McDonald, 
so  that  it  may  be  granted  that  the  operations  were  skilfully  performed  and 
the  important  facts  duly  appreciated  and  accurately  recorded. 

The  records  for  the  sixteen  years  up  to  1899  formed  the  basis  of  a  previous 
statistical  paper  by  myself,  dealing  with  the  channels  of  infection  in  tuber- 
culosis, and  the  probable  ratio  obtaining  between  infection  by  the  alimentary 
and  by  the  respiratory  systems.  This  appeared  in  the  Edinburgh  Hospital 
Reports  for  1900.  In  1904  I  reinvestigated  them,  adding  the  cases  which 
had  come  to  post-mortem  examination  during  the  intervening  five  years. 
I  studied  them,  for  the  third  time,  with  care,  in  1907,  and  presented  a  paper, 
based  upon  them,  at  the  Congress  of  the  Royal  Institute  of  Public  Health, 
held  at  Douglas,  Isle  of  Man,  in  July  of  that  year.  During  the  present 
summer  (1908)  I  have  again  revised  the  whole  series  of  cases,  even  more 
minutely  than  before,  and  in  still  greater  detail.  The  present  paper  is  thus 
the  product  of  an  investigation,  conducted  four  times,  at  long  intervals,  the 
frequent  revisals  tending  to  greater  accuracy  in  the  final  results. 

During  the  twenty-one  years  a  total  of  1085  post-mortem  examinations 
were  conducted;  and  of  them,  421,  or  38.8  per  cent.,  were  upon  children  who 
had  died  from  tuberculosis.  The  records  of  413  cases  were  sufficiently  full 
for  analysis,  and  with  these  this  paper  is  concerned. 

Infants  under  one  year  of  age  were  not  admitted  to  the  Hospital  until 
toward  the  close  of  1888,  so  that  the  cases  fall  naturally  into  two  groups  or 

367 


368  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

series,  the  first  including  all  cases  up  to  the  end  of  1888,  and  the  second  in- 
cluding those  occurring  in  the  years  1889-1904. 

In  the  former  period  250  post-mortems  were  conducted,  of  which  105 
were  upon  cases  of  tuberculosis;  in  the  latter  308  cases  of  tuberculosis  were 
met  among  835  cases  of  all  kinds  investigated  in  the  post-mortem  room. 
Incidentally  it  may  be  noted  that  the  second  group,  even  though  it  contain  a 
larger  percentage  of  young  children  in  the  first  two  years  of  life,  represents 
a  fall  of  6  per  cent,  in  the  number  of  deaths  from  tuberculosis,  relatively  to 
the  total  number  of  deaths  from  all  causes. 

One  must  bear  in  mind  that  these  are  post-mortem  statistics,  and  while 
it  is  perfectly  legitimate  to  employ  them  in  drawing  certain  general  con- 
clusions, they  must  not  be  taken  as  even  indicating,  with  any  approach  to 
accuracy,  the  conditions  prevailing  during  life,  but  they  show  clearly  the 
great  importance  of  the  lymphatic  glands  in  the  invasion  and  dissemination 
of  tuberculosis.  It  is  from  this  aspect  principally  that  I  shall  view  the  sub- 
ject of  tuberculosis  on  this  occasion. 

Ages  of  the  Cases. 

The  accompanying  chart  is  plotted  to  show  the  percentages  of  the  cases 
which  died  at  the  various  ages  up  to  thirteen  years.  The  ages  were  available 
in  363  cases.  Out  of  that  number,  247,  or  68  per  cent.,  were  under  five 
years  of  age,  and  116,  or  31.9  per  cent.,  were  over  that  age.  One  hundred 
and  ninety-six,  or  54  per  cent.,  died  during  the  first  three  years  of  life,  and 
only  two  out  of  the  whole  number  were  over  twelve  years  of  age.  The  highest 
mortality  occurred  in  the  second  year  of  life  in  both  series.  Following  this, 
the  chart  shows  a  rapid  decline  to  the  fourth  year  in  the  first  series,  and  to  the 
fifth  year  in  the  second  series,  succeeded  by  a  transient  rise  in  the  fifth  year 
in  the  first,  and  in  the  sixth  year  in  the  second  series.  If  the  totals  at  each 
age  are  combined  and  percentages  taken,  as  indicated  by  the  crosses  on  the 
chart,  a  single  wave,  having  its  maximum  in  the  sixth  year,  replaces  these 
two  secondary  rises,  and  thereafter,  in  the  second  half  of  the  period  of  thir- 
teen years,  the  death-rate  steadily  falls,  except  for  a  slight  rise  in  the  eighth 
year. 

The  first  tables  show  the  number  of  cases  out  of  the  whole  413  in  which 
the  lymphatic  glands  were  tuberculous  to  the  naked  eye.  Doubtless  the 
percentages  would  have  been  considerably  increased  had  the  glands  in  every 
case  been  examined  microscopically. 

Pathologists  are  well  aware  that  early  proliferative  changes,  character- 
istic of  the  tuberculous  process,  with  demonstrable  tubercle  bacilli,  often  to 
be  found  only  after  a  prolonged  search,  can  be  detected  in  apparently  non- 
tuberculous  glands  in  tuberculous  children,  as  well  as  in  children  to  all  ap- 
pearance free  from  such  infection.     Moreover,  it  is  also  accepted  as  proved 


TUBERCULOSIS   IN    CHILDREN. — SHENNAN. 


369 


that  tubercle  bacilli  frequently  lie  "latent"  in  lymphatic  glands  in  tuber- 
culous or  healthy  children,  without  inducing  any  proliferative  changes  and 
only  detectable  by  the  tuberculosis  produced  in  experimental  animals  by 
inoculation  of  the  glands.  One  of  the  best  summaries  of  the  work  carried  out 
on  these  lines,  by  numerous  observers,  is  given  by  Rabinowitsch.*  She 
points  out  that  in  feeding  experiments  latent  bacilli  are  more  often  found  in 
the  mesenteric  glands  than  in  the  thoracic. 


CHART  TO  SHOW  AGES  OF  363   CHILDREN,  IN   PERCENTAGES   OF    THE 
NUMBERS  OCCURRING  IN  EACH  YEAR  OF  LIFE. 

A,  First  Series.     B,  Second  Series. 

Ordinate  gives  ■percentages;  abscissa  gives  ages. 


0-1 

1-2 

?.-^ 

;?-4 

4-5 

^ft 

ft -7 

7-8 

fi-.9 

f?-10 

10-n 

11-1? 

12-13 

30 
25 
20 
15 
10 
5 

A 

n. 

1  \ 

'\ 

•J 

1 1 

1  \ 

/ 

". 

/ 

T  — 

1 

\  \ 

/ 

/ 

1 

\A 

4- 

( 

« t 

( 

« \ 

J   ■ 

\ 

■  1 
1 

\ 

1 

\ 

\., 

1 

\ 

• 

A 

/'n 

fs 

A 

''>) 

'    X 

Ar 

y 

r  -^y 

»/ 

v/ 

^J 

I  »x 

1 

V 

V 

K 

\ 

\ 

•  «». 

-♦n, 

a' 

N 

s: 

X 

•-^. 

"-% 

X 

W 

^. 

A 

3 

20 

15 

5 

8 

6 

5 

a 

4 

4 

3 

3 

2 

B 
A 

41 

75 

42 

23 

15 

24 

19 

13 

8 

7 

4 

6 

3^ 

23.2 

17.4 

5.7 

9.3 

7.0 

5.7 

9.3 

4.6 

4.6 

3.5 

3.5 

2.3 

"bi 

|li^ 

270 

15.0 

8^ 

5.4 

8.6 

6.9 

4.6 

2.9  2.5l 

1.4: 

24 

*  Berl.  klin.  Wochenschr.,  1907,  S.  35. 


370  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

FIRST  SERIES.— TABLE  I. 

Lymphatic  Glands. 

Tuberculous  in  97  out  of  105  Cases  (92.4  per  cent.). 

Mediastinal  glands  affected  in 87  (82.8  per  cent.) 

Abdominal  glands  affected  in 71  (67.6  per  cent.) 

Mediastinal  and  abdominal  together  in 61  (58.1  per  cent.) 

Mediastinal  alone  in 26  (24.7  per  cent.) 

Abdominal  alone  in 10  (  9.5  per  cent.) 

97 

SECOND  SERIES.— TABLE  I. 

Lymphatic  Glands. 

Tuberculous  in  243  out  of  308  Cases  (78.8  per  cent.). 

Mediastinal  glands  affected  in 194  (62.9  per  cent.) 

Abdominal  glands  affected  in 1.50  (48.7  per  cent.) 

Mediastinal  and  abdominal  together  in 101  (32.1  per  cent.) 

Mediastinal  alone  in 93  (30.2  per  cent.) 

Abdominal  alone  in 45  (14.6  per  cent.) 

Thorax  not  examined  in 4  (  1.3  per  cent.) 

243  (78.2  per  cent.) 

The  first  table,  in  my  first  series,  shows  that  in  only  eight  cases  out  of  a 
total  of  105  were  the  lymphatic  glands  to  all  a^Dpearance  unaffected.  In  the 
great  majority  of  the  cases  in  which  the  glands  were  affected  both  mediastinal 
and  abdominal  glands  were  attacked.  In  the  remaining  cases,  in  which  the 
disease  was  localized  to  one  or  the  other  of  these  groups  of  glands,  the  thoracic 
were  affected  twice  as  often  as  the  abdominal. 

In  the  second  series,  while  in  a  large  percentage  of  cases — ^nearly  half — 
both  thoracic  and  abdominal  glands  were  simultaneously  affected,  the  larger 
number  showed  the  disease  localized  to  one  or  other  of  these  groups,  and  of 
these  the  thoracic  glands  were  affected  alone  in  twice  as  many  cases  as  the 
abdominal,  just  as  in  the  former  series. 

The  subsequent  tables  show  that  from  the  standpoint  of  dissemination  of 
tuberculosis  throughout  the  body,  the  thoracic  gland  tuberculosis  is  the  more 
important  and  common. 

The  second  tables  deal  with  visible  tuberculosis  of  the  mediastinal  glands, 
including  root,  bronchial  and  tracheal,  anterior  and  posterior  mediastinal 
glands,  particularly  the  first  two  groups,  and  show  its  relationship  to  tuber- 
culosis of  the  lungs. 

It  will  be  at  once  noticed  that,  in  a  comparatively  small  proportion  of 
the  cases,  older  lesions,  to  which  the  glandular  condition  was  probably 
secondaiy,  were  present  in  the  lungs;  whereas  in  the  majority  of  cases  more 
recent  pulmonary  tuberculosis,  designated  as  "tuberculous  bronchopneu- 
monia," "rapid  caseation,"  "caseous  pneumonia,"  "mihary  tuberculosis," 


TUBERCULOSIS    IN   CHILDREN. — SHENNAN. 


371 


etc.,  was  present.  These  lung  conditions  were  certainly,  in  many  cases  at 
least,  secondary  to  the  disease  of  the  glands.  This  bears  out  the  accepted 
opinion  that  in  very  young  children — and  the  majority  of  those  examined 
were  under  five  years  of  age — it  is  the  exception  to  meet  with  primary  tuber- 
culosis of  the  lungs. 

FIRST  SERIES.— TABLE  II. 
Tuberculosis  of  the  Mediastinal  Glands  (87  cases). 


Associated  with  pulmonary  excavation 35 

Associated  with  tuberculous  bronchopneumonia  or 
caseous  areas  only 25 


Associated  with  miliary  tubercles  only,  in  the  lungs  8 
With  early  caseation  and  miliary  tuberculosis  in 

lungs 2 

With  tuberculous  bronchopneumonia,  and  mihary 

tuberculosis 4 

With  ulceration  into  bronchus — naked  eye 2 

Without  evident  tuberculosis  of  lungs 11 

87 


Cavities  old 14 

Cavities  recent 19 

Both  varieties 2 

Tuberculous     bronchopneu- 
monia   17 

Caseous  areas 5 

Both  conditions  together 3 


SECOND  SERIES.— TABLE  II. 
Tuberculosis  of  the  Mediastinal  Glands  (194  cases). 

(  Cavities  old 19 

Associated  with  pulmonary  excavation 53  ]  Cavities  recent 25 

I   Both  varieties 9 

I  Tuberculous      bronchopneu- 

Associated  with  tuberculous  bronchopneumonia  or       I       monia 19 

caseous  areas  only  (no  excavation) 42  1   Caseous  areas 18 

1   Both  conditions 5 

Associated    with    miliary  tuberculosis,    only,  in         J   ^^    ^8    of    these,    localized 
2unes  57  1       spread     from     glands     or 

^  '_  ■ [       pleura. 

With  caseous  areas  and  miliary  tuberculosis  in 

lungs 10 

With  tuberculous  bronchopneumonia  and  miliary 

tuberculosis  in  lungs 8 

With  old  interstitial  tubercidosis 1 

Apparently  secondary  to  tuberculosis  of  the  thy- 
mus gland 1 

Without  evident  tuberculosis  of  the  lungs 22 

Total 194 

It  is  also  interesting  to  note  that  in  1 1  cases  out  of  87  in  the  first  series, 
and  in  22  cases  out  of  194  in  the  second  series,  there  was  no  evident  lesion, 
either  primary  or  secondary,  in  the  lungs. 

Table  III  in  each  series  analyzes  the  cases  in  which  the  abdominal  glands 
were  visibly  tuberculous,  and  gives  valuable  indications  of  the  relationship 
of  tabes  mesenterica  to  tuberculosis  of  the  lungs  on  the  one  side,  and  to 
ulceration  of  the  intestine  on  the  other. 


372 


SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 


FIRST  SERIES— TABLE  III. 
Tuberculosis  of  Abdominal  Glands  (71  cases). 


Glands   caseous,   accompanying 
intestinal  ulceration 38 


Caseation  of  glands  without  any 
intestinal  ulceration 33 


Old  excavation  of  lung 9 

Recent  excavation,  evidently  primary 7 

Recent  excavation,  relation  to  intestinal  ulcera- 
tion doubtful 1 

Ulceration  primary 16 

Ulceration  more  recent  than  caseation  of  gland; 

no  excavation  of  lung 4 

Thorax  not  examined 1 

Old  excavation  of  lung 3 

Recent  excavation  of  lung 6 

No  excavation  of  lungs 24 

"""Tl^eSon  on"£ttoe'*°"'l5  {  O"'  ■"  ^4  cases  showing  excavation  of  the  lungs. 
In  8  of  the  15  tabes  mesenterica  was  present,  in  7  being  evidently  secondary  to  the 
excavation. 

SECOND  SERIES.— TABLE  III. 
Tuberculosis  of  Abdominal  Glands  (150  cases). 

Old  excavation  of  lung 13 

Recent  excavation,  evidently  primary 9 

Recent  excavation,  probably  secondary 4 

Ulceration  of  larynx,  bad  family  history 1 

Ulceration  and  matting  of  intestine 12 

Perforating  ulcers  and  matting  of  intestine 6 

Ulcers  evidently  primary,  no  matting,  no  lung 
tubercle,  or  only  miliary  tubercle  or  early 

tuberculous  bronchopneumonia 11 

Early  ulceration;  glands  in  thorax  and  abdo- 
men advanced  caseation;  no  excavation  of 
lung;  occasionally  miliary  tubercles;  pos- 
sible double  infection 19 

Doubtful  origin 3 

Excavation  of  lungs 17 

Old  fibro-caseous  nodules  in  lungs 6 

No  excavation  of  lungs 49 


Glands   caseous,   accompanying 
intestinal  ulceration 78 


Glands  caseous,  no  accompany- 
ing intestinal  ulceration 72 


Out  of  72  cases  with  excavation. 


Excavation    of    lungs,    without       / 

ulceration  of  intestine 27  \ 

In  14  of  the  27  tabes  mesenterica  was  present,  in  13  being  evidently  secondary 


It  shows  that  in  nearly  half  of  the  cases,  in  which  the  abdominal  glands 
were  tuberculous,  there  was  no  ulceration  of  the  intestine,  and,  moreover, 
that  in  a  large  number  of  these  cases  there  was  no  excavation  of  the  lungs — 24 
in  the  first  series  and  49  in  the  second  series. 

If  one  now  examines  all  the  cases,  in  the  whole  413  cases  under  review,  in 
which  excavation  of  the  lungs  had  occurred, — 106  in  all, — it  is  found  that 
42  presented  no  sign  of  ulceration  of  the  intestine,  but  in  22  of  these  the  ab- 
dominal glands  were  caseous,  in  20  of  them  this  condition  being  evidently 
secondary  to  the  lung  excavation — 7  in  the  first  series  and  13  in  the  second. 

The  tables  also  give  support  to  the  opinion  that  multiple  infection  may 
take  place,  for  example,  in  cases  in  which,  without  excavation  of  the  lungs, 
ulceration  of  the  intestine  may  exist  of  later  date  than  the  tuberculosis  of 
the  abdominal  glands. 


TUBERCULOSIS  "IN   CHILDREN. — SHENNAN.  373 

FIRST  SERIES.— TABLE  IV. 
Ulceration  of  Intestine  without  Excavation  of  Lungs  (26  cases,  24.8  per  cent.). 

Old  caseous  nodules  in  lungs 3 

Tuberculous  bronchopneumonia  or  rapid  caseation 

in  lungs 14 

Miliary  tubercles  in  lungs 5 

Apparently  no  tuberculosis  in  lung 6 

Abdominal  glands  affected  in 20 

With    tuberculous    broncho- 


Mediastinal  glands  affected  in 21 


pneumonia  or  rapid  casea- 
tion   13 

With    miliary    tubercles    in 

lungs 3 

Abdominal  and  mediastinal  affected  together 17 

(Therefore,  abdominal  alone  in  3  cases,  and  mediastinal  alone  in  4  cases.) 
Associated  with  tuberculous  meningitis  in  11  cases. 

SECOND  SERIES.— TABLE  IV. 
Ulceration  of  Intestine  without  Excavation  of  Lungs  (60  cases,  19.4  per  cent.). 

Tuberculous  bronchopneumonia 1 

Miliary  tuberculosis;  perforated  intestinal  ulcer .    1 

(  Active  caseation  in  lungs 6 

Caseous  abdominal  glands 26      ^'^"^  tubercles  in  lungs 10 

°  Old  caseous  nodule  in  lungs ...   3 

[  No  evident  tubercle  in  lungs ...   7 
Caseous  mediastinal  glands 1      Acute  tuberculosis  in  lungs ....   1 

(Active  caseation  in  lungs 14 
MUiary  tuberculosis  in  lungs ...  14 
Old  caseous  nodule  m  lung 1 
No  evident  tubercle  in  lungs ...   2 


Tuberculous  meningitis 28 


Active  tuberculous  caseation  in 

lungs    12 

Miliary  tuberculosis  in  lungs ...  1 1 
Old  caseous  nodule  in  lung  ....  1 
No  evident  tubercle  in  lungs ...   4 

The  fourth  table  in  each  series  is  to  be  taken  as  complementary  to  the 
third  tables.  They  analyze  all  the  cases,  out  of  the  413,  in  which  ulceration 
of  the  intestine  had  occurred  without  preexisting  excavation  of  the  lungs. 
It  is  most  remarkable  that  no  fewer  than  86  cases  come  under  this  category, 
or  20.8  per  cent,  of  the  whole.  Even  allowing  for  a  large  margin  of  error, 
there  is  still  a  sufficient  number  left  to  prove  that,  in  this  country  at  least, 
primary  ulceration  of  the  intestine  occurs  frequently.  Knowing  of  these 
cases,  I  have  never  been  able  to  accept  statements  as  to  the  extreme  rarity  of 
primary  intestinal  ulceration,  at  least,  as  applicable  to  the  conditions  pre- 
vailing in  Scotland. 

Talcing  the  two  series  together,  it  is  seen  that,  in  these  cases,  the  abdom- 
inal glands  were  more  often  tuberculous  than  the  mediastinal,  though  in 
many  cases  both  groups  were  affected;  and,  secondly,  that  the  fatal  event, 
in  nearly  half  the  cases,  was  due  to  tuberculous  meningitis. 

It  is  hardly  necessary  to  insist  that  these  observations  have  no  bearing  on, 
or  reference  to,  the  question  of  the  nature  or  source — bovine  or  human — of 


374  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

the  tubercle  bacillus  causing  the  lesions.  These  tables  cannot,  from  their 
very  nature,  give  any  indication  in  that  direction. 

The  fifth  tables  analyze  the  cases  of  tuberculous  meningitis,  and  detail 
the  immediate  foci  from  which,  so  far  as  could  be  determined,  the  spread  of 
tubercle  had  taken  place  to  the  meninges.  It  may  be  allowed  that  all,  or 
practically  all,  cases  of  tuberculous  meningitis  have  a  fatal  termination,  so 
that  these  tables  may  be  taken  as  conforming  more  closely  to  clinical  ex- 
perience than  the  others  I  have  presented. 

It  will  be  seen  that  in  the  great  majority  of  cases,  the  lymphatic  glands 
apparently  have  provided  the  focus  from  which  dissemination  has  taken 
place,  with  tuberculous  meningitis  as  the  important  result,  and  that  the 
thoracic  groups  have  been  more  frequently  implicated  than  the  abdominal. 
It  is  worthy  of  note  that  only  in  a  few  cases  could  one  determine  that  ex- 
cavation of  the  lungs  or  ulceration  of  the  intestine  had  proved  the  immediate 
focus  from  which  the  spread  had  taken  place.  The  last  tables  (No.  IV) 
showed  that  in  many  cases  of  apparently  primary  ulceration  of  the  intestine 
tuberculous  meningitis  had  supervened,  but  in  the  majority  of  these  the 
actual  focus  whence  the  disease  had  spread  to  the  meninges  appeared  to  be 
furnished  rather  by  the  associated,  broken-down,  caseous  lymphatic  glands. 
The  relative  importance  of  the  intestinal  ulceration  and  the  glandular  tuber- 
culosis cannot,  of  course,  be  determined  absolutely  in  all  these  cases  after 
the  lapse  of  so  many  years. 

FIRST  SERIES.— TABLE  V. 
Tuberculous  Meningitis. 
In  41  Cases  out  of  105  (39  per  cent.). 
Primary  jocus  apparently  in:  Dissemination  apparently  from  active  secondary 

changes  in: 

(Lung:   acute  tuberculous  bronchopneumonia 
or  active  caseation     .    ■••■;••.•   ^ 
feoitenmg  mediastmal  glands,  no  tubercle  in 
lungs,  or  miliary  tubercles  only 8 

Abdominal  glands 4  (  J^T^^'' ••  V  ;•••.••  r  V  '  J ? 

1,  Soitenmg  abdominal  glands 1 

Mediastinal  and  abdominal  glands  2  I   n^Jt^^ ;•••••• r 

°  \  boitening  glands 1 

Excavation  of  lungs 6  I  ^  ^ij^^  • j'- '  ■."• "  {'  \'  '  \ i 

°  \  boitenmg  mediastmal  glands 1 

{  Mediastinal 2 

Intestinal  ulceration 9       Glands:  \   Abdominal 6 

[  Mediastinal  and  abdominal 1 

Of  doubtful  origin  and  dissemination 3 

Large  cavity  lung;    early  ulceration  of  intestine;    some  mediastinal  and  abdominal 

glands  calcareous 1 

Glands  caseous  in  neck,  groin,  mediastinum,  and  abdomen,  with  early  excavation  and 

ulceration 1 

Doubtful  whether  excavation  or  bronchial  glands  primary 1 

41 
In  12  cases  there  were  caseous  masses  in  some  part  of  the  brain. 


TUBERCULOSIS   IN   CHILDREN. — SHENNAN.  375 

SECOND  SERIES.— TABLE  V. 

Tuberculous  Meningitis. 
In  143  cases  out  of  308  (46.4  per  cent.). 
Primary  foctcs  apparently  in:  Dissemination  apparently  from  active  second- 

ary changes  in: 

f  Lungs 9 

Mediastinal  glands 62    -j  qi     j^ .  /  Mediastinal 49' 

[  ■  \  Abdominal 4 

/  Lungs 1 

\  Abdominal  glands 8 

Mediastinal        and        abdominal        f  Lungs 8 

glands 23    \  (  Mediastinal IP 

[  Glands:  \  Abdominal V 

[  Both  affected 3^ 

Lungs 2 

Intestinal  ulcer 1 

I                   (  Mediastinal 3 

[  Glands:  -j  Abdominal 2 

[  Both  groups  affected 1 


Abdominal  glands 9 


Excavation  or  old  focus  in  lungs  9 


Acute    tuberculous  bronchopneu- 
monia     3' 

(  Ulceration 2 

Intestinal  ulceration 9    \  n^„^r^c.  /  Mediastinal 3* 

[  ^^ands.  ^  Abdominal 4? 

Of  doubtful  origin  and  dissemination 22' 

Possibly  from  tuberculous  disease  of  bone 8^ 

*  Tuberculous  "tumor"  in  3  of  these  cases,  in  brain. 
^Tuberculous  "tumor"  in  2  of  these  cases,  in  brain. 
'  Tuberculous  "tumor"  in  1  of  these  cases,  in  brain. 

Now,  if  we  suppose  that  the  great  majority  of  glands  affected  with  tuber- 
culosis really  do  contain  the  "bovine"  bacillus,  as  some  authorities  maintain, 
we  should  have  to  conclude  that  the  majority  of  the  cases  in  which  tubercu- 
lous meningitis  had  caused  death  had  been  infected  with  "bovine"  bacilli. 
The  necessary  corollary  would-be  that  most  of  these  cases,  forming  altogether 
44.5  per  cent,  of  the  whole  number,  had  been  infected  from  a  bovine  source. 

The  recent  reports  of  the  British  Royal  Commission  on  Tuberculosis 
show,  however,  that  the  views  of  these  authors  are  not  wholly  correct,  and 
that  bacilU  of  both  types,  "human"  and  "bovine,"  can  be  separated  from 
caseous  lymphatic  glands,  whether  abdominal  or  mediastinal. 

Eastwood  divides  his  strains  of  tubercle  bacilli  into  five  grades,  wliich 
lessen  in  virulence  for  bovines  as  their  growth  upon  nutrient  media  becomes 
more  luxuriant.  These  characters  are  to  be  taken  as,  in  a  general  way,  sep- 
arating the  strains  into  the  bacilU  of  "bovine"  type  and  those  of  "human" 
type.  The  tables  he  has  drawn  up  show  that,  in  the  five  grades,  tubercle 
bacilli  have  been  separated  from  lymphatic  glands  taken  from  all  parts  of 
the  body  in  13,  6,  9,  13,  and  10  cases  respectively.* 

*  Royal  Commission  on  Tuberculosis,  Human  and  Animal.  Second  Interim  Report, 
Part  II,  Appendix,  vol.  iv,  pp.  227  to  233. 


376  sixth  international  congress  on  tuberculosis. 

Summary. 

1.  One  thousand  and  eighty-five  cases  came  under  review,  of  wliich  413 
had  died  from  tuberculosis.  These  cases  are  examined  in  two  series,  the 
first  containing  105,  and  the  second  containing  308  cases. 

2.  The  ages  of  the  cases  varied  from  three  months  to  thirteen  years,  ap- 
proximately 68  per  cent,  being  under  five  years  of  age. 

3.  The  lymphatic  glands  were  tuberculous  in  97  cases  (92.4  per  cent.)  in 
the  first  series  and  in  243  cases  (78.8  per  cent.)  in  the  second  series.  The 
mediastinal  glands  were  more  frequently  affected  than  the  abdominal  glands, 
and  dissemination  took  place  more  frequently,  apparently,  from  the  former 
group. 

4.  Tuberculosis  of  the  mediastinal  glands  was  commonly  unaccompanied 
by  primary  tuberculosis  of  the  lungs,  but  was  frequently  accompanied  by 
recent  tuberculosis  of  these  organs,  in  many  cases  evidently  secondary  to 
the  gland  tuberculosis. 

5.  In  nearly  half  of  the  cases  of  tabes  mesenterica,  there  was  no  ulcera- 
tion of  the  intestines,  and  in  one-third  of  the  cases  there  was  no  excavation  of 
the  lungs,  although  in  some  of  them  the  lungs  showed  early  manifestations 
of  tuberculosis.  In  a  number  of  cases  excavation  of  the  lungs  was  not  fol- 
lowed by  ulceration  of  the  intestines,  although  in  about  half  of  such  cases 
tabes  mesenterica  had  resulted,  the  excavation  being  of  some  standing. 

6.  Primary  ulceration  of  the  intestines,  in  absence  of  any  prior  excavation 
of  the  lungs,  was  frequently  found.  It  was  usually  accompanied  by  casea- 
tion of  lymphatic  glands — mesenteric  or  abdominal,  or  both  simultaneously. 
In  a  large  proportion  of  these  cases  the  immediate  cause  of  death  was  tuber- 
culous meningitis. 

7.  Death  was  due  to  tuberculous  meningitis  in  44.5  per  cent,  of  the  cases. 
Dissemination  had  taken  place  in  most  cases,  apparently,  from  caseous 
lymphatic  glands,  principally  of  the  mediastinal  groups.  In  24  cases  of 
meningitis  tuberculous  caseous  nodules  were  found  in  some  part  of  the  en- 
cephalon,  but  these  did  not  seem  in  all  cases  to  have  given  rise  to  the  spread 
to  the  meninges. 


Tuberculosis  en  los  Ninos,  con  Referenda,  en  Particular,  A  la  Tuberculosis 
de  las  Glandulas  Linfaticas. — (Shennan.) 

Estos  cuadros  compendian  los  resultados  de  una  investigaci6n  acerca 
de  los  informes  de  autopsias  en  casos  de  tuberculosis  en  ninos  que  fueron 
pacientes  internos  del  Hospital  Real  para  Niiios  Enfermos,  Edimburgh. 

Demas  de  1,000  autopsias,  407  se  practicaron  en  niiios  que  murieron  de 
tuberculosis  y  estos  cuadros  estan  basados  sobre  los  ultimos  307  de  estos 
casos.     Las  conclusiones  importantes  se  refieren  a  la  frecuencia  on  que  la  en- 


TUBERCULOSIS    IN   CHILDREN. SHENNAN.  377 

fermeclad  ocurre  en  las  glandulas  linfaticas  y  a  la  diseininaci6n  tuberculosa 
que  de  ellas  partes. 

1.  Las  glandulas  se  encontraron  afectadas  en  una  gran  proporcion  de 
los  casos^ — 77.8  por  ciento. 

2.  Las  glandulas  toracicas  mas  frecuentemente  que  las  abdominales. 

3.  Excavacion  de  los  pulmones  comparativamente  rara. 

4.  En  la  tuberculosis  de  las  glandulas  abdominales,  50  por  ciento  se  en- 
contraron libres  de  ulceras  intestinales  y  en  dos  terceras  partes  de  los  casos 
que  mostraban  ulceracion  intestinal  no  habia  cavidades  en  los  pulmones. 

5.  La  ulceracion  de  los  intestinos  se  present©  en  60  casos  del  numero 
total  (19.5  por  ciento)  sin  que  cavidad  alguna  en  los  pulmones  le  haya 
precedido. 

6.  La  muerte  fue  debida  a  la  meningitis  tuberculosa  como  causa  inme- 
diata  en  137  casos  (-14.6  por  ciento)  y  segun  aparece,  esta  ultima  fue  debida 
a  la  diseminacion  proveniente  de  glandulas  caseosas — especialmente  del 
torax — en  la  mayorla  de  los  casos. 


La  Tuberculose  chez  les  Enfants,  surtout  celle  des  Glandes  lymphatiques. 

— (Shennan.) 

Ces  listes  resument  les  resultats  d'une  investigation  des  protocoles 
d'autopsies,  des  enfants  tuberculeux  regus  au  Royal  Hospital  for  Sick  Chil- 
dren a  Edinbourg. 

Sur  plus  de  1000  autopsies,  407  furent  faites  sur  des  enfants  morts  de  la 
tuberculose  et  ces  listes  resument  les  derniers  307  de  ces  cas. 

Les  faits  importants  exposes  se  rapportent  a  I'incidence  de  la  maladie 
dans  les  glandes  honphatiques  et  a  la  dissemination  de  la  tuberculose  de 
ces  glandes. 

1.  Ces  glandes  ont  ete  affectees  dans  une  fort  grande  proportion  des 
cas :  77.8  pour  cent. 

2.  Les  glandes  thoraciques  ont  ete  affectees  plus  souvent  que  les  glandes 
abdominales, 

3.  Ou  a  trouve  relativement  peu  d'excavations  dans  les  poumons. 

4.  Dans  la  tuberculose  des  glandes  abdominales,  50  pour  cent  n'ont  pas 
6t6  accompagnees  d'ulc^rations  des  intestins,  et  dans  deux- tiers  des  cas  ayant 
ulcerations  des  intestins,  il  n'y  avait  pas  d'excavation  dans  les  poumons. 

5.  Dans  60  cas  tout  compris  (19.5  pom*  cent),  il  existait  ulceration  des 
intestins,  sans  aucune  excavation  pulmonaire  prec^dente. 

6.  Dans  137  de  cas  (44.6  pour  cent),  la  mort  etait  immddiatement  due  k 
la  meningite  tuberculeuse,  ce  qui  dans  la  plupart  des  cas  semblait  suivre  la 
dissemination  des  glandes  cas^euses,  surtout  des  glandes  thoraciques. 


378  SIXTH   INTERNATIONAL  CONGRESS   ON   TUBERCULOSIS. 

Tuberkulose  bei  Kindern,  besonders  mit  Riicksicht  auf  die  Lymphdriisen- 
Tuberkulose. — (Shennan.) 

Die  folgenden  Tabellen  veranschaulichen  die  Ergebnisse  einer  Analisie- 
rung  der  Autopsien  jener  Falle  von  Tuberkulose  in  Kindern,  die  im  R,oyal 
Hospital  for  Sick  Children,  Edinburgh,  behandelt  wurden. 

Von  melir  als  1000  Autopsien  betrafen  407  solche  Kinder,  die  an  Tuber- 
kulose gestorben  waren;  den  Tabellen  liegen  die  letzten  307  dieser  Falle  zu 
Grunde. 

Wichtige  Momente  sind  die  Haufigkeit,  mit  welcher  die  Erlo'ankung 
in  den  Lymphdriisen  vorgefunden  wurde  und  die  Dissemination  der  Tuber- 
kulose aus  diesen  Driisen. 

1.  Affection  der  Driisen  war  in  einer  sehr  ho  hen  Proportion  vorhanden 
—77.8  Prozent. 

2.  Die  thoracalen  Driisen  waren  haufiger  angregriffen  als  die  abdomi- 
nalen, 

3.  Lungen-Cavernen  wurden  verhaltnismassig  selten  vorgefunden. 

4.  In  50  Prozent  der  Falle  von  Tuberkulose  der  abdominalen  Driisen 
war  keine  Ulceration  des  Darmes  nachweisbar;  in  zwei  Dritteln  jener  Falle, 
wo  sich  Darmgeschwiire  vorfanden,  war  keine  Cavernenbildung  in  den 
Lungen  vorhanden. 

5.  Insgesamt  zeigten  60  Falle  (19.5  Prozent)  von  Darmgeschwiirbildung 
keine  Lungencavernen. 

6.  In  137  Fallen  (44.6  Prozent)  war  der  Tod  direkt  auf  tuberkulose 
Meningitis  zuriickzufiihren,  und  schien  diese  zumeist  eine  Folge  von  Dis- 
semination aus  vorwiegend  thoracalen  Driisenvorgangen  gewesen  zu  sein. 


THE  RELATION  OF  MEASLES,  WHOOPING-COUGH  AND 
INFLUENZA  TO  TUBERCULOSIS  IN  CHILDHOOD. 

By  Dr.  Edgar  P.  Copeland, 

Washington,  D.  C. 


Were  tuberculosis  but  an  occasional  concomitant  of  these  infections, 
their  wide-spread  prevalence  would,  alone,  warrant  a  careful  consideration. 
The  public,  at  least,  has  long  entertained  a  fallacious  idea  with  respect  to 
these  common  diseases  of  childhood.  Indeed,  measles  and  whooping-cough 
have  been,  and  continue  to  be,  popularly  regarded  as  conditions  trivial  in 
nature — something  for  the  child  to  have  and  have  done  with.  The  dangers 
of  such  a  policy  cannot  be  overestimated.  Dr.  Newton  Pitt,  in  a  recent 
issue  of  the  "Guy's  Hospital  Report,"  has  characterized  measles  and  whoop- 
ing-cough as  the  most  important  factors  in  the  mortality  of  early  life.  In- 
fluenza— ^no  doubt  because  of  its  apparent  low  mortality  as  compared  with 
its  incidence — has  been  looked  upon  with  absolute  indifference. 

It  is  not,  however,  my  purpose  to  discuss  these  diseases  and  the  host  of 
complications  that  contribute  to  such  mortality  as  is  observed,  but  rather  to 
emphasize  the  relationship  existing  between  these  infections,  on  the  one 
hand,  and  tuberculosis,  in  all  its  protean  manifestations,  on  the  other. 

Tuberculosis  is  observed  to  follow  upon  these  diseases,  both  in  the  role 
of  complication  and  sequel,  but  in  just  what  proportion  of  cases  is  difficult 
to  determine.  Bentzel  and  Jiirgenson  find  from  5  to  16  per  cent.  While  I 
hope  to  show  that  this  tuberculosis  is,  for  the  most  part,  dependent  upon  a 
preexisting  latent  focus,  the  possibility  of  infection  from  direct  exposure  at 
the  time  is  conceded,  and  should  be  borne  in  mind. 

Some  idea  of  the  frequency  with  which  these  diseases  are  associated  may 
be  gathered  from  the  figures  of  Ganghofner  in  Prague.  In  176  autopsies  on 
children  dying  from  measles,  55,  or  31.2  per  cent,,  had  tuberculosis.  Heller, 
of  Kiel,  in  714  cases  dead  from  acute  infectious  disease,  including  measles, 
found  140,  or  19.6  per  cent.,  tuberculous;  Councilman,  of  Boston,  in  220 
cases,  found  35,  or  16.0  per  cent.,  tuberculous;  Baginsky,  of  Berhn,  in  806, 
found  144,  or  17,8  per  cent,,  tuberculous;  Ganghofner  himself,  of  Prague, 
in  973  cases,  found  253,  or  28  per  cent,,  tuberculous.  These  figures  represent 
the  definite  presence  of  tuberculosis  in  association  with  the  infectious  diseases, 
and  more  particularly  with  measles,  but  do  not  enlighten  us  as  to  the  relation 

379 


380  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

existing.  No  doubt  in  a  large  proportion  death  resulted  from  some  cause 
but  remotely  related  to  the  tuberculous  conditions.  Did  tuberculosis  follow 
the  acute  infections  in  all  cases  in  which  there  existed  a  latent  tuberculous 
focus,  the  mortality  would,  I  am  sure,  be  greatly  increased.  For  instance, 
in  a  recent  epidemic  of  measles  in  the  Washington  Orphan  Asylum  there  was 
not,  in  75  cases,  a  single  case  complicated  with  tuberculosis;  nor  has  tuber- 
culosis manifested  itself  in  any  of  the  patients  after  a  lapse  of  four  years.  It 
is  interesting  to  note  that  but  one  case  of  bronchopneumonia  was  observed, 
though  the  children  average  not  over  seven  years.  Certainly  some  of  those 
children  must  be  potentially  tuberculous.  On  the  other  hand,  no  figures 
available  can  convey  an  adequate  idea  of  the  large  number  of  cases  in  which 
the  manifestation  of  tuberculosis  is  so  long  delayed  as  to  obscure  the  role  of 
previous  disease  in  its  development.  The  average  length  of  time  elapsing 
between  the  infection  and  the  appearance  of  definite  lesions  in  tuberculosis 
is  variously  estimated  as  from  a  few  months  to  years. 

The  difficulties  met  with  in  an  attempt  to  arrive  at  definite  conclusions 
with  regard  to  this  relationship  are  obvious.  The  records  of  hospitals  re- 
ceiving measles  and  whooping-cough  in  no  instance  deal  with  the  sequels 
of  these  diseases;  few  post-mortem  examinations  are  had  in  such  institu- 
tions, in  this  country;  while  the  previous  histories  of  tuberculous  patients 
are  rendered  unreliable  from  the  very  nature  of  the  disease.  For  example, 
a  colored  female,  aged  seven  years,  dying  in  The  Children's  Hospital  of  this 
city,  has  just  come  to  autopsy  at  the  time  of  writing.  The  examination 
showed  general  miliary  tuberculosis,  with  lesions  most  advanced  in  the  lungs. 
Now,  in  spite  of  the  fact  that  this  child  has  a  record  of  having  had  measles 
six  months  before,  there  is  no  information  that  would  make  it  even  reasonable 
to  assume  that  latent  tuberculosis  did  not  previously  exist.  Landis,  of 
Philadelphia,  in  a  recent  investigation  of  a  series  of  cases  of  measles,  states, 
that  "but  little  information  was  gained  in  this  study  as  to  the  relation  exist- 
ing between  tuberculosis  and  measles." 

Considering  the  role  of  latent  foci  in  the  production  of  tuberculosis,  it 
seems  important  to  emphasize  the  prevalence  of  the  condition  in  cliildren. 
According  to  Burton  Fanning,  it  is  stated  that  a  more  careful  examination  of 
the  offspring  of  tuberculous  women  and  cows  reveals  the  tubercle  bacilli  in  a 
larger  proportion.  The  number  of  infants  affected  steadily  increases  until, 
at  the  age  of  one  year,  autopsies  show  7  and  8  per  cent.  Kelynack  states 
that  40  per  cent,  of  all  children  dying  under  fifteen  years  of  age  show  evi- 
dence of  tuberculosis.  Those  of  us  working  in  The  Children's  Hospital  of 
this  city,  where  we  have  to  do  with  children  under  twelve  years,  are  impressed 
with  the  number  of  cases  of  tuberculosis  coming  to  autopsy,  though  the 
peculiar  susceptibility  of  the  negro  race  must  be  taken  into  consideration. 
This  latent  tuberculosis,  where  the  balance  of  power  between  the  invader 


MEASLES,    WHOOPING-COUGH    AND    INFLUENZA. COPELAND,  381 

and  the  internal  resistance  is  not  well  maintained,  is  evidenced,  as  charac- 
terized by  Goodhart,  by  "a  tribe  of  glandular  and  other  affections,  ophthal- 
mia, discharges  from  ears,  suppurating  glands  in  the  neck,  and  caseating 
mediastinal  glands."  In  addition  to  these  visible  signs  of  disease,  there  is, 
what  can  best  be  expressed  by  quoting  Kelynack,  "  An  immense  amount  of 
impairment  of  health,  crippling  and  lowering  of  power  to  resist  morbid  in- 
fluences, resulting  directly  from  tuberculosis,  without  producing  a  mortality 
that  can  be  statistically  expressed." 

In  considering  the  role  of  the  acute  infections  in  the  etiology  of  tuber- 
culosis, we  are  unfortunate  in  not  being  in  possession  of  more  definite  facts 
with  respect  to  the  exciting  causes  of  at  least  two  of  these  conditions.  We 
can,  however,  observe  certain  clinical  and  pathological  phenomena  common 
to  all. 

They  are  alike  characterized  by  a  highly  infectious  nature,  by  a  tendency 
to  occur  epidemically,  by  a  marked  catarrhal  inflammation  of  the  mucous 
membranes  over  the  entire  body,  and  by  greatly  lowered  resistance.  This 
catarrhal  condition  constitutes  a  part  of  these  diseases,  and  is  not  to  be  con- 
fused with  the  processes  observed  to  follow  upon  infection  with  the  strepto- 
coccus and  other  secondary  invaders.  It  is,  furthermore,  attended  with 
intense  hyperemia  and  lymphatic  activity. 

In  this  catarrhal  condition  of  the  respiratory  passages  we  have,  I  believe, 
the  key  to  whatever  connection  exists  between  tuberculosis  and  these  diseases. 
Not,  however,  in  the  sense  that  such  inflammation  predisposes  to  infection, 
but  rather  in  that  it  promotes  the  generalization  of  a  localized  latent  process. 
In  discussing  the  etiology  of  tuberculosis,  Fowler  says  that:  "Having  regard 
to  the  extreme  prevalence  of  catarrhal  affections  of  the  bronchi  and  the 
relatively  small  number  of  cases  in  which  tuberculosis  follows,  I  am  disposed 
to  think  that  the  importance  of  this  factor  in  the  etiology  of  the  disease  has 
been  exaggerated." 

The  assumption  that  catarrhal  affections  of  the  respiratory  mucous 
membranes  heighten  the  susceptibility  to  tuberculous  invasion  is,  of  course, 
based  upon  the  acceptance  of  the  inhalation  theory  of  infection. 

With  respect  to  children,  it  would  certainly  seem  true  that  in  the  light  of 
constantly  growing  mass  of  evidence  the  importance  of  the  inhalation  theory 
has  proportionately  decreased.  Von  Behring,  Calmette,  Guerin,  Deliarde 
and  others  in  Europe,  and  Schroeder  and  Cotton,  of  the  U.  S.  Department  of 
Agriculture,  have  shown  experimentally  in  animals,  and  in  some  instances 
clinically  in  children,  the  greater  dangers  of  ingestion.  They  have  pointed 
out,  all  but  conclusively,  that  our  ideas  of  what  constituted  the  evidence  of 
the  intestinal  origin  of  the  disease  were  entirely  at  fault.  Mesenteric  lymph- 
nodes  have  been  demonstrated  to  contain  tubercle  bacilli  even  in  the  absence 
of  apparent  pathological  lesion,  and  the  thoracic  lymph-nodes  have  been 


382  SIXTH    INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS 

shown  to  be  primary  points  of  manifest  change,  irrespective  of  the  site  of  in- 
fection or  inoculation.  Coupled  with  these  facts  comes  the  knowledge  of  the 
all  but  negative  potency  of  the  tubercle  bacilli  of  dried  secretion. 

I  have  called  attention  to  the  h}'peremia  and  lymphatic  activity  as- 
sociated with  catarrhs  of  the  infections.  Having  in  mind  the  prevalence  of 
latent  tuberculosis,  we  can  easily  picture  the  mechanism  of  dissemination  in 
the  production  of  active  disease.  The  lymph-streams  draining  the  inflamed 
areas  of  mucous  membrane,  swollen  to  many  times  their  normal  volume, 
flowing  through  these  foci  of  potential  mischief,  set  free  and  carry  into  the 
circulation  tubercle  bacilli,  for  distribution  over  the  entire  body.  The  re- 
sulting picture  depends,  first,  upon  the  amount  and  virulence  of  the  in- 
fectious agent;  and,  secondly,  upon  the  relative  resistance  of  the  tissue  to 
which  it  is  conveyed.  The  condition  most  commonly  observed  in  children 
is  that  of  a  general  miliary  tuberculosis,  with  lesions  most  advanced  in  either 
lungs  or  meninges.  According  to  Nothnagel,  meningitis  is  seen  in  the  large 
majority  of  cases.  Our  post-mortem  work  at  the  Children's  Hospital  leads 
me  to  believe  that,  with  the  possible  exception  of  disease  of  bones  and  glands, 
tuberculosis  in  children  is  almost  invariably  general  in  character.  We  have, 
however,  found  the  lesions  in  the  lungs  most  advanced  in  the  large  proportion 
of  all  cases.  In  284  autopsies,  151  showed  predominating  pulmonary  changes, 
whereas  but  46  showed  meningeal  changes  in  excess.  Doubtless  the  cases 
of  bronchopneumonia  upon  which  tuberculosis  is  presumed  to  have  become 
engrafted  are  cases  of  miliary  tuberculosis  from  the  beginning.  Such  rapid 
diffusion  of  tubercle  is  not  often  seen  confined  to  one  system.  When  the 
osseous  system  becomes  the  locus  minoris  resistentiae,  the  development  of 
manifest  lesions  is  usually  delayed  for  months,  and  even  years. 

The  role  of  latent  tuberculosis  is  nowhere  more  strikingly  shown  than  in 
institutions  for  children,  where  the  incidence  of  the  disease  after  the  acute 
infections  is  high.  Under  such  conditions  the  opportunities  for  infection 
obviously  do  not  exist.  Dr.  Nothrup,  discussing  measles  in  this  connection, 
says:  "There  remains,  now  that  diphtheria  is  removed  from  the  list,  but  one 
scourge  in  institutions  for  children — a  plague,  and  that  plague  is  measles." 
Of  course,  the  incidence  of  tuberculosis  is  not  represented  by  the  mortality, 
but  other  than  the  definite  cases  observed,  contributes  largely  to  such  mor- 
tality. Henoch  is  responsible  for  the  statement  that  the  child  is  to  be  feared 
more  than  the  disease  in  an  attack  of  measles,  and,  further,  that  he  has  not 
observed  danger  except  with  those  potentially  tuberculous. 

Whooping-cough  and  influenza  occupy  the  same  position  relatively  as 
measles.  The  frequency  with  which  the  former  complicates  measles  adds, 
of  course,  a  double  danger.  The  extreme  grade  of  inanition  so  often  observed 
in  whooping-cough,  even  with  its  associated  depression,  seems  insufficient, 
in  the  absence  of  latent  disease,  to  produce  disseminated  tubercle. 


MEASLES,    WHOOPING-COUGH    AND   INFLUENZA. — COPELAND.  383 

Influenza,  while  giving  rise  to  the  most  perplexing  and  alarming  pul- 
monary phenomena,  is  seldom,  if  ever,  followed  by  tuberculosis  v/here  such 
condition  did  not  previously  exist.  While  mortality  tables  show  a  high 
death-rate  from  tuberculosis  during  epidemics  of  influenza,  they  represent 
an  increased  mortality  rather  than  an  increased  morbidity. 

Galbraeth,  in  investigating  the  frequency  with  which  persons  in  the 
pretuberculous  state  are  affected,  found  in  150  consecutive  cases  51  per  cent, 
infected  with  the  Peiffer  bacillus,  and  characterized  influenza  as  one  of  the 
causes  that  permits  the  spread  of  tuberculous  mischief.  No  doubt,  as  Burton 
Fanning  says,  it  is  extremely  common  to  call  influenza  what  is  in  reality 
nothing  more  than  the  fever  and  constitutional  disturbance  of  commencing 
tuberculosis.  It  is  most  certain  that  the  tuberculosis  lung  offers  a  most 
favorable  medium  for  the  reception  and  persistent  growth  of  the  influenza 
bacillus. 

In  the  light  of  our  present  knowledge,  the  following  conclusions  would 
seem  justified:  that,  taking  into  consideration  the  enormous  morbidity  of 
measles,  whooping-cough,  and  influenza,  the  incidence  of  tuberculosis  as  a 
complication  or  sequel  is  of  relatively  small  importance;  that  its  develop- 
ment is  all  but  invariably  dependent  upon  the  preexistence  of  latent  disease; 
and  that  its  dissemination  is  probably  due  to  lymphatic  activity  resulting 
from  the  pulmonary  inflammations  associated  with  these  diseases. 

I  would  not,  however,  be  understood  as  presenting  anything  upon  which 
could  be  based  the  relinquishment  or  the  relaxing  of  one  element  of  the  safe- 
guard which  should  be  thrown  around  all,  weak  and  strong  alike,  at  such 
times.  It  is  greatly  to  be  hoped  that  the  great  minds  so  dihgently  and  un- 
selfishly devoted  to  unravehng  the  mysteries  of  this  potent  enemy  of  the 
animal  kingdom  may  at  this  Congress  present  such  facts  as  will  serve  to 
throw  greater  light  upon  the  subject  that  I  have  endeavored  to  treat. 


La  Relacion  de  las  Enfermedades  Infecciosas,  Sarampion,  Tos  Ferina  6 
Influenza  con  la  Tuberculosis. — (Copeland.) 

El  tema  es  interesante  debido  a  la  extensa  diseminacion  de  estas  enfer- 
medades. Es  mirado  por  el  publico  con  insuficiente  seriedad.  Aunque  la 
tuberculosis  se  observa  como  una  consecuencia  6  comphcacion  del  sarampion, 
la  tos  ferina  y  la  influenza,  la  relacion  y  proporcion  de  estas  enfermedades 
y  la  tuberculosis  es  dificil  de  determinar.  Las  estadisticas  demuestran 
lesiones  tuberculosas  en  31.2%  de  los  fallecidos  a  consecuencias  del  sarampion. 
Importancia  de  la  prevalencia  de  la  tuberculosis  latente.  La  inflamacion 
catarral  de  las  membranas  mucosas,  asociada  de  hiperemia  y  actividad 
linfatica,  es  comun  d  todas  las  tres  clases  de  enfermedad,  llave  de  la  relacion. 


384  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

La  actividad  linfatica  determina  la  diseminacion  en  el  organismo.  El 
cuadro  revela  por  lo  general  una  tuberculosis  miliar,  los  sintomas  pulmonares 
predominan.  La  influenza  aunque  da  origen  a  muchas  condiciones  oscuras 
del  pecho,  es  raramente  seguida  de  tuberculosis  exeptuando  los  casos  en 
que  una  condicion  latente  existe. 

Conclusion: — Conciderando  la  prevalencia  del  sarampion,  la  tos  ferina 
6  influenza,  la  tuberculosis  no  se  manifiesta  con  frecuencia  suficiente  para 
ser  de  gran  importancia :  que  su  desarrollo  en  todo  caso  depende  de  la  pre- 
sencia  de  un  foco  latente  de  la  enfermedad;  y  que  la  diseminacion  es  directa- 
mente  debida  a  la  actividad  linfatica. 


Die  Beziehungen  der  Infectionskrankheiten — Masern,  Keuchhusten  und 
Influenza — zur  Tuberkulose  bei  Kindern. — (Copeland.) 

Der  Gegenstand  ist  von  Wichtigkeit  wegen  der  weitverbreiteten  Natur 
dieser  Krankheiten.  Die  Offentlichkeit  betrachtet  dies  mit  ungeniigendem 
Ernste.  Obwohl  wahrgenommen  ist,  dass  Tuberkulose  nach  Masern,  Keuch- 
husten und  Influenza  als  Folge  und  Complication  auftritt,  ist  es  schwer  die 
Beziehungen  und  das  Verhaltnis  von  Fallen  zu  bestimmen,  in  denen  die 
Verwandtschaft  beobachtet  wird.  Die  Statistik  zeigt  tuberkulose  Verlet- 
zungen  in  31.2%  der  Todesfalle  von  Masern.  Haufigkeit  von  latenter  Tu- 
berkulose von  Wichtigkeit.  Catarrhale  Entziindung  der  Schleimhaute  in 
Verbindung  mit  Hyperamie  und  lymphatischer  Activitat  ist  alien  drei  Krank- 
heiten gemeinsam,  der  Schliissel  zur  Verwandtschaft.  Lymphatische  Activi- 
tat bestimmt  eine  Verbreitung  iiber  den  Korper.  Das  Krankheitsbild  ist 
gewohnlich  eine  allgemeine  Miliartuberkulose  mit  vorwiegenden  Lungen- 
symptomen.  Influenza,  obwohl  zu  vielen  unklaren  Brusterscheinungen  die 
Ursache  gebend,  ist  selten  von  Tuberkeln  begleitet,  ausgenommen  wo  ein 
latenter  Zustand  vorhanden  ist.  Schlussfolgerungen :  Wenn  man  die 
Haufigkeit  von  Masern,  Keuchhusten  und  Influenza  in  Betracht  zieht, 
folgt  Tuberkulose  nicht  geniigend  oft,  um  von  grosser  Wichtigkeit  zu  sein; 
ihre  Ent\^dcklung  hangt  in  alien  Fallen  von  einem  latenten  Erreger  der 
Krankheit  ab  und  die  Ausbreitung  ist  eine  dirkte  Folge  lymphatischer 
Activitat  mit  vorwiegenden  Lungensymptomen. 


ON  VON  PIROUET'S  CUTANEOUS  TUBERCULIN  TEST 
ON  CHILDREN  IN  THE  FIRST  YEAR  OF  INFANCY. 

By  Prof.  O.  Medin,  M.D., 

Stockholm. 


Since  last  year,  when  I  became  familiar  with  cutaneous  tuberculin  test, 
as  a  diagnostic  in  tuberculosis,  I  have  used  it  on  a  number  of  children  of  all 
ages,  as  well  as  on  adults.  On  the  present  occasion,  however,  I  shall  confine 
myself  to  an  account  of  the  employment  of  this  means  in  respect  to  children 
of  the  tenderest  age. 

To  begin  with,  I  must  mention  that  the  experiments  carried  out  by  some 
of  my  colleagues  in  Stockholm  had  altogether  discouraged  me  from  making 
any  attempt  to  use  the  so-called  ophthalmo-reaction.  The  accounts  given 
by  physicians  abroad  of  the  evil  results  of  its  employment  had  already  warned 
me  against  it,  and,  as  I  said  just  now,  my  fears  were  fully  confirmed  by  what 
I  saw  at  home.  It  would  never  even  enter  my  mind  to  use  the  ophthalmo- 
reaction on  older  children,  some  of  whom  show  intense  reactions;  the  risk 
of  exciting  a  more  or  less  acute  conjunctivitis,  not  to  speak  of  the  possibility 
of  exciting  keratitis,  is  not  needlessly  to  be  incurred.  We  have  not  the  right 
to  expose  any  one  to  the  danger  of  such  a  misfortune :  at  least,  the  test  should 
never  be  made  unless  the  patient  voluntarily  consents  to  expose  himself  to  it, 
and  is  capable  of  clearly  understanding  the  risk  he  is  running.  As  a  rule, 
there  should  be  no  thought  of  making  experiments  on  infants  which  can 
cause  suffering  and  bodily  harm,  and  more  especially  is  this  the  case  with  re- 
gard to  poor  little  orphans. 

Last  autumn,  after  I  had  seen  in  Vienna  some  of  the  children  whom 
Dr.  von  Pirquet  had  tested  with  the  cutaneous  tuberculin  inoculation,  and 
having  on  that  occasion  convinced  myself  that  even  those  children  showing 
intensive  reaction  did  not  suffer  in  any  way  from  the  operation,  I  tried  the 
experiment  on  a  number  of  older  children  in  Stockholm.  As  the  result  of 
numerous  experiments  on  these  infants  I  became  fully  persuaded  of  the 
harmlessness  of  the  cutaneous  method,  as  not  in  one  single  instance  did  it 
cause  them  any  inconvenience  when  carried  out  in  the  manner  prescribed  by 
Dr.  von  Pirquet,  whose  method  I  consistently  followed.  Having  made 
quite  sure  of  this  fact,  I  considered  that  I  could  safely  begin  my  experiments 
with  the  very  youngest  infants,  and  it  is  of  the  experience  gained  in  this 
VOL.  11—13  385 


386  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

cutaneous  tuberculin  inoculation  of  children  of  less  than  one  year  old  that  I 
wish  to  say  a  few  words. 

I  commenced  my  experiments  in  November  of  last  year  among  the  chil- 
dren at  the  Foundling  Hospital  (Allmanna  Barnhuset)  in  Stockholm.  Since 
that  date,  with  the  help  of  my  assistants,  I  have  carried  out  this  cutaneous 
tuberculin  inoculation  on  no  less  than  400  children  under  one  year  old.  I 
have  almost  uniformly  inoculated  the  lower  part  of  the  arms;  at  the  first  in- 
oculation I  have  as  uniformly  inoculated  in  three  different  spots,  and  with 
a  different  mixture  at  each  spot — at  the  highest  point  with  a  25  per  cent, 
tuberculin  mixture;  at  that  in  the  middle  with  a  10  per  cent,  solution;  and 
at  the  lowest  point  of  inoculation,  with  control-liquid  without  tuberculin, 
this  control-liquid  consisting  of  one  part  carbolic-glycerin  and  two  parts 
physiological  salt  solution.  I  think  I  ought  also  to  mention  that  I  have  used 
Koch's  "Alt-tuberculin"  and  the  inoculation-syringe  prescribed  by  Dr.  von 
Pirquet. 

The  results  of  my  inoculations  can  be  summed  up  in  a  few  words.  As 
before  mentioned,  we  have  inoculated  no  less  than  400  children  under  one 
year  of  age,  about  350  of  them  being  but  a  few  months  old.  In  general,  we 
know  little  or  nothing  as  to  the  health  of  the  parents,  or  of  the  previous 
condition  of  health  of  the  infants  when  they  are  brought  in  to  the  hospital; 
the  greater  number  appeared  to  be  entirely  free  from  disease  and  well  nour- 
ished. But  while  symptoms  of  all  kinds  of  the  more  or  less  ordinary  diseases 
peculiar  to  infants  were  found  among  some  of  the  children,  it  was  only  now 
and  then  that  there  was  any  real  reason  to  suspect  that  they  had  been,  or 
were  then,  suffering  from  tuberculosis.  It  is,  as  a  rule,  no  very  easy  thing 
to  diagnose  with  any  degree  of  certainty  the  existence  of  tuberculosis  in 
children  during  the  first  few  months  of  their  lives,  but  to  do  so  at  an  early 
stage  of  the  disease  becomes  a  matter  of  exceptional  difficulty,  and  so  every 
diagnostic  expedient  of  any  value  is  always  very  welcome.  It  is  not  im- 
possiljle  that  the  cutaneous  tuberculin  inoculation  can  become  such  a  means, 
but  it  will  certainly  never  be  decisive  for  the  diagnosis  of  tuberculosis,  or 
not  tuberculosis,  in  the  case  of  the  very  youngest  infants  any  more  than  in 
adults. 

Of  the  400  children  tested,  390  did  not  show  the  slightest  trace  of  a 
reaction  in  the  neighborhood  of  the  inoculated  spots.  Those  spots  that  had 
been  inoculated  with  the  tuberculin  mixture  had  precisely  the  same  ap- 
pearance as  those  which  had  been  treated  with  the  control-liquid.  In  58 
of  these  cases  the  inoculation  was  renewed — in  one  case  once,  and  in  some 
instances  several  times,  but  always  with  the  same  negative  results. 

Of  the  390  children  just  mentioned,  who  never  showed  any  reaction,  31 
died  after  a  short  time,  or  within  a  few  months  at  most.  Twenty-nine  of 
these  31  died  of  other  diseases,  and  the  post-mortem  examination  showed  no 


VON    PIRQUET's   test   in   infancy. — MEDIN.  387 

trace  of  tuberculosis.  In  two  cases,  however,  tuberculosis  was  found  in 
optima  forma.  One  of  these  two  children  came  under  my  observation  on 
November  23,  1907,  and  the  cutaneous  tuberculin  test  was  made  the  same 
day.  The  child  had  pronounced  symptoms  of  tuberculous  meningitis,  but 
showed  no  sign  of  reaction  to  the  tuberculin  test,  either  cutaneous  or  general. 
It  died  two  days  afterward.  This  child  was  seven  months  old.  In  this  in- 
stance the  observation  made  by  von  Pirquet  was  confirmed,  that  during  the 
last  few  days  (about  ten)  before  death,  children  do  not  show  any  reaction, 
even  if,  or,  possibly  just  because,  they  are  suffering  from  very  extensive  and 
greatly  developed  tuberculous  changes. 

The  other  child,  which  had  not  shown  any  reaction,  but  which,  after 
death,  was  found  to  have  been  infected  with  tuberculosis,  was  two  months 
old  when  it  was  inoculated,  on  April  7,  1907.  The  child  was  suspected  of 
having  syphilis,  and  toward  the  end  of  the  month  it  showed  evident  signs 
of  this  disease.  On  May  11th  the  child  began  to  be  sub  febrile  with  irregular 
temperature-curves;  a  little  later,  fine  atelectatic  rales  were  observed  in  the 
left  lung.  On  May  25th  the  child  died  without  having  presented  such  sj^mp- 
toms  that  any  diagnosis  of  tuberculosis  could  be  made.  It  is  true  that  tuber- 
culosis develops  itself  with  the  greatest  rapidity  in  children  during  the  first 
months  of  life,  and  it  is  not  altogether  impossible  that  when  the  child  last 
mentioned  was  inoculated,  on  April  7th,  it  had  not  then  been  attacked  by 
the  disease.  Still,  I  am  more  inclined  to  believe  that  infection  had  taken 
place  before  the  date  mentioned,  and  that  the  child  did  not  show  reaction 
in  consequence  of  some  circumstance  with  which  we  are  unacquainted, 
but  which  probably  in  exceptional  cases  has  a  disturbing  influence  on  the 
experiment. 

Of  the  400  infants  inoculated,  only  10  have  reacted  positively;  in  other 
words,  in  the  case  of  infants  only  2.5  per  cent,  show  any  reaction.  This  is 
a  fact  of  great  importance.  We  do  not  find  nearty  so  many  tuberculous  in- 
dividuals among  infants  under  one  year  of  age  as  we  do  among  older  cliikh'en, 
and  this  tends  to  confirm  my  opinion  that  tuberculosis  is  not  often  conveyed 
to  children  during  their  earliest  infancy,  to  become  latent  and  break  out  at 
some  future  time.  If  such  latent  tuberculosis  often  existed  in  infants,  it  is 
in  the  highest  degree  likely  that  a  greater  number  of  them  would,  too,  show 
reaction  to  the  tuberculin  test.  We  see,  for  example,  how  older  cliildren, 
even  if  they  are  suffering  from  some  very  slight  tuberculous  glandular  or 
osseous  affection,  react  very  intensely;  and  why,  then,  should  not  the  re- 
action display  itself  in  the  same  way  in  the  case  of  infants.  It  is  certain, 
too,  that  those  infants  who  really  are  infected  with  tuberculosis  show  re- 
action, in  nearly  every  case,  to  the  cutaneous  tuberculin  test. 

Of  the  10  children  who  reacted  positively,  two  have  since  died,  both  of 
them  at  autopsy  showing  extensive  tuberculous  changes.     One  of  these  two 


388  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

was  born  April  30,  1908;  was  received  into  the  Foundling's  Hospital  on  June 
2d,  weighing  then  only  3250  grams.  It  was  brought  up  by  the  bottle  and 
suffered  from  chronic  enteritis.  Was  given  the  breast,  but  showed  no  im- 
provement; in  the  middle  of  July  it  was  noticed  that  the  child  had  a  spas- 
modic cough  and  that  the  spleen  was  somewhat  enlarged.  The  temperature 
was  the  whole  time  very  irregular.  On  July  21st  a  cutaneous  tuberculin  test 
was  made  in  accordance  with  von  Pirquet's  method.  Twenty-four  hours 
later  a  positive  reaction  was  observed.  The  hacking  cough  continued  and 
the  child  grew  thinner  and  thinner,  weighing  on  July  28th  only  2820  grams; 
nothing  abnormal  could  be  clearly  distinguished  in  the  lungs.  The  child  died 
on  July  30th,  the  autopsy  showing  tuberculosis  with  caseous  transformation  in 
the  bronchial  lymph-nodes,  miliary  tuberculosis  of  the  lungs,  the  spleen,  the 
liver,  and  of  the  mesenteric  lymph-glands.  In  this  case  tuberculosis  had  been 
suspected  on  account  of  the  clinical  symptoms,  but  no  definite  localization 
could  be  determined.  The  cutaneous  tuberculin  test  decided  the  diagnosis, 
which  was  confirmed  by  the  autopsy. 

The  other  child  who  also  showed  the  reaction  was  seven  months  old 
when  it  was  admitted  to  the  Foundling  Hospital  on  November  19th.  It  was 
atrophic  and  had  small  but  clearly  palpable  swellings  of  the  lymphatic 
glands  of  the  neck  and  was  soon  suspected  of  having  tuberculosis. 

On  December  3d  Pirquet's  test  was  made  and  resulted  positively, 
although  feebly  so.  There  was  no  reaction  at  the  control  spot,  but  at  the 
other  spots  there  were  seen  very  small  and  somewhat  irregular  patches  of  a 
rather  vivid  red  color,  and  of  inconsiderable  height.  On  a  fresh  inoculation 
being  made  on  December  8th,  the  reaction  was  not  quite  so  pronounced,  and 
at  a  final  attempt,  made  on  the  10th  of  the  same  month,  no  reaction  at  all 
was  observed,  either  after  twenty-four,  or  forty-eight  hours.  The  child  died 
on  December  29th  and  presented  at  autopsy  tuberculosis  in  nearly  all  parts 
of  the  body.  I  made  an  observation  in  respect  to  this  case  which  may  pos- 
sibly be  of  some  importance.  The  child  was  inoculated  on  December  3d, 
and  on  the  following  day  its  temperature  rose,  remained  high  till  the  5th,  and 
on  the  6th  rose  to  38.8°  C.  (101.8°  F.),  and  on  the  7th  returned  to  normal. 
On  December  8th  it  was  observed  that  the  child  had  an  exanthem  with  very 
small  spots  which  disappeared  after  four  days.  It  is  possible  that  this  rise 
in  temperature  and  this  exanthem  were  the  results  of  the  tuberculin  inocula- 
tion. But  before  I  can  place  any  confidence  in  this  hypothesis,  I  should  like 
to  see  the  phenomenon  confirmed  by  the  results  of  further  inoculations. 

Finally  I  should  like  to  say  a  few  words  on  the  eight  infants  who  reacted 
positively,  but  who  are  still  alive.  At  the  first  inoculation,  one  child  did 
not  react  at  all  and  another  very  feebly,  but  at  a  second  inoculation,  made  a 
couple  of  weeks  afterward,  a  reaction  was  clearly  visible.  One  of  these  two 
infants  was  nine  months  old  when  it  was  admitted  to  the  Foundling  Hospital 


VON   PIRQUET's   test  in   infancy. — MEDIN.  389 

on  April  29th  last;  at  the  end  of  May  it  began  to  cough  and  showed  signs  of 
bronchitis.  On  May  28th  an  inoculation  was  made,  and  the  following  day 
there  was  observed  an  inconsiderable  redness  at  the  spot  which  had  been 
inoculated  with  the  25  per  cent,  tuberculin  mixture.  The  reaction  was  not 
considered  as  positive.  It  was  the  same  case  with  an  inoculation  made  on 
June  11th.  The  cough  and  the  bronchitis  continued.  On  June  25th  a 
fresh  inoculation  was  made,  and  reaction  was  clearly  visible,  for  both  the 
10  per  cent,  and  the  25  per  cent,  mixture.  I  have  not  the  least  doubt  but 
that  this  infant  is  suffering  from  tuberculosis. 

Another  child,  five  months  old,  which  suffered  from  a  spasmodic  cough 
and  had  been  attacked  for  a  week  previously  by  repeated  convulsions,  did 
not  show  reaction  on  July  14th,  but  reacted  positively  on  July  31st.  It  is 
probable  that  this  child,  too,  has  tuberculosis,  although  at  the  end  of  August 
no  clinical  proof  of  the  accuracy  of  this  diagnosis  had  yet  been  noticed. 

The  6  infants  who  reacted  positively  on  the  first  occasion  of  inoculation 
and  who  are  still  living,  reacted  in  very  different  ways.  One  child,  with 
evident  clinical  symptoms,  reacted  at  once  and  very  clearly.  Another,  that 
reacted  plainly  on  July  31st,  has  not  shown  clinical  signs  of  tuberculosis,  but 
it  is  very  possible  that  it  is  suffering  from  the  disease.  A  tliird  child  that 
reacted  clearly  to  the  test  was  a  strong,  well-nourished,  five-weeks-old  baby 
that  showed  no  sign  of  the  disease;  but  it  must  be  remarked  that  this  child's 
mother  has  suffered  from  tuberculosis  of  the  spine  for  two  years,  and  now  has 
pulmonary  tuberculosis  also.  Is  it  possible  that  such  a  child  can  be  tuber- 
culinized  while  still  an  embryo,  and  that  is  the  reason  it  reacts  positively 
without  itself  being  affected  with  tuberculosis?  It  will  be  of  the  greatest 
interest  to  follow  the  development  of  this  case.  Up  to  the  age  of  two  months 
the  child  is  still  perfectly  healthy.  Three  infants,  who  did  not  react  other- 
wise than  by  the  appearance  of  an  unimportant  redness  twenty-four  hours 
after  inoculation  around  the  25  per  cent,  inoculated  spot,  have  not  yet,  it  is 
true,  shown  any  signs  of  tuberculosis,  but  I  suspect  all  the  same  that  they  are 
not  altogether  free  from  the  disease.  This  suspicion  is  based  partly  on  the 
fact  that  infants  really  free  from  tuberculosis  never  show  the  least  sign  of 
redness  around  the  inoculated  spots  twenty-four  hours  afterward,  and  partly 
on  the  observation  made,  that  infants  who  at  first  reacted  in  the  uncertain 
way  described,  have  later  on  shown  a  perfectly  evident  reaction.  My  con- 
viction is  this,  that  in  von  Pirquet's  cutaneous  tuberculin  test  made  on 
infants  in  the  first  year  of  their  age,  even  the  least  sign  of  a  reaction  is  of  im- 
portance. Should  this  supposition  of  mine  be  confirmed  by  further  experi- 
ments, it  must  then  be  acknowledged  that  this  harmless  and  easily  executed 
operation  is  of  great  value  as  a  diagnostic  auxiliary  when  it  is  a  question 
of  diagnosing  tuberculosis  in  infants  during  the  first  few  months  of  their  lives. 


THE  OPSONIC  CONTENT  OF  BREAST-MILK. 
By  Dr.  Wm.  J.  Butler, 

Chicago. 


Ehrlich,  in  his  studies  on  immunity  through  heredity  and  nursing,  found 
that  the  young  of  mice  immunized  against  ricin,  abrin,  and  tetanus  possessed 
a  passive  immunity,  and  that  this  increased  and  continued  while  they  were 
nursed  by  the  immunized  animals,  but  that  it  diminished  when  they  were 
suckled  by  normal  mice.  He  also  found  that  if  the  young  of  normal  mice 
were  nursed  by  mice  immunized  against  ricin,  abrin,  and  tetanus,  they 
acquired  a  passive  immunity  against  these  agents.  This  proved  that  their 
antitoxins  were  excreted  by  the  mammary  glands  of  the  immunized  animals. 
AVernicke  was  able  to  demonstrate  the  excretion  of  antitoxin  in  the  milk 
of  mothers  immunized  against  diphtheria. 

Later,  investigations  were  carried  on  to  determine  if  antibodies  were 
excreted  in  this  manner.  Widal  and  Sicard  found  agglutinins  in  the  milk 
of  mothers  who  had  typhoid.  Kraus  demonstrated  agglutinins  in  the  milk 
of  animals  immunized  against  typhoid,  colon,  and  cholera  bacilli.  ]\Ioro, 
on  the  other  hand,  could  not  find  bactericidal  substances  in  the  breast- 
milk  of  healthy  mothers.  Turton  and  Appleton  inquired  into  the  opsonic 
contents  of  human  and  cows'  milk  for  staphylococcus  and  tubercle  bacillus 
wdth  negative  results.  Recently  Eisler  and  Sohma  have  investigated  the 
opsonins  of  milk  of  normal  and  immunized  animals,  finding  none  in  the 
former  case,  but  found  them  in  the  milk  of  immune  animals. 

As  the  first  part  of  this  work,  directed  to  investigating  the  opsonins  of 
breast-milk,  experiments  were  undertaken   with  a  view  of  determining: 

First,  if  the  breast-milk  of  normal  mothers  contains  opsonins. 

Second,  if  so,  to  what  extent  compared  with  their  blood-serum. 

Third,  if  cows'  milk  contains  opsonins. 

Wright's  technic  was  adhered  to  in  making  the  examinations,  whicb 
were  carried  out  for  four  organisms:  namely,  staphylococcus  aureus,  gono- 
coccus,  pneumococcus,  and  tubercle  bacillus.  For  the  first  three  mentioned 
organisms,  emulsions  of  about  equal  thickness,  averaging  six  to  seven  to 
the  cell,  were  used.  For  the  tubercle  bacillus,  an  emulsion  averaging  1.25 
to  1.5  to  a  cell  was  employed.     The  breast-milk  was  obtained  from  mothers 

390 


THE    OPSONIC   CONTENT   OF   BREAST-MILK. — BUTLER. 


391 


within  ten  days  from  date  of  parturition.  Their  blood  was  taken  at  the 
same  time.     The  cow's  milk  was  obtained  from  a  local  dairy. 

As  controls,  the  different  organisms  were  examined  with  blood-corpuscles 
alone,  in  order  to  ascertain  the  extent  of  spontaneous  phagocytosis.  The 
washed  blood-corpuscles  of  a  laboratory  worker  were  used.  The  number  of 
bacteria  taken  up  by  fifty  leukocjrtes  in  each  slide,  representing  respectively 
the  examinations  with  staphylococcus,  gonococcus,  pneumococcus,  and 
tubercle  bacillus,  were  counted  and  the  average  phagoc}i:ic  count  per 
leukocyte  for  each  organism  was  determined  and  these  counts  are  entered 
in  the  tables,* 

Following  are  the  results  of  examinations : 

STAPHYLOCOCCUS.    . 


MOTHEB 

Average  Phagocytic  Count 
Feb  Cell. 

Milk  Index. 

Average 
Milk  Index 

Blood-Serum. 

Breast-Milk. 

Gilson 

6.62 
6.54 
6.64 
7.48 
6.78 

.16 
.16 

.18 
.14 
.10 

.023    1 

.023 

.026 

.02 

.014 

Gunther 

Maronla 

.022 

Shoner 

Easily 

Cows'  Milk:   Average  phagocytic  count,  .10;    Index,  .014. 

Without  serum  or  milk:   Average  phagocytic  count,  .34;   Index,  .05. 


GONOCOCCUS. 


Mother. 

Average  Phagocytic  Count. 

Milk  Index. 

Average 
Milk  Index. 

Blood-Serum. 

Breast-Milk. 

Gilson 

Gunther 

Maronla 

Shoner 

Easily 

6.32 
6.16 
6.28 
6.28 
5.89 

.12 
.24 
.12 

.24 
.08 

.02      1 

.04 

.02 

.04 

.013 

.025 

Cows'  Milk:  Average  phagocytic  count,  .04;   Index,  .006. 

Without  serum  or  milk:   Average  phagocytic  count,  .1;  Index,  .016. 

*  The  indices  of  the  human  milk  are  figured  against  the  blood-serum  of  the  cor- 
responding mother.  The  average  index  of  the  human  milk  and  the  indices  of  the 
cows'  milk  and  the  salt  solution  are  figured  against  the  average  phagocytic  count  of 
the  sera. 


392  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

PNEUMOCOCCUS. 


Average  Phagocytic  Count. 

Milk  Index. 

Average 
Milk  Index. 

Blood-Serum. 

Breast-Milk. 

Gilson 

6.52 

6.04 

5.6 

6.14 

6.06 

.62 

.8 
.78 
.54 
.66 

.1         1 

.13 

.13 

.09 

.11 

■ 

Gunther 

.11 

Shoner     

Easily 

Cows'  Millc:  Average  phagocytic  count,  .12;   Index,  .02. 

Without  serum  or  milk:   Average  phagocytic  count,  .18;  Index,  .03. 


TUBERCLE  BACILLUS. 


Average  Phagocytic  Count. 

Milk  Index. 

Average 
Milk  Index 

Blood-Serum. 

Breast-Milk. 

Gilson 

1..54 
1.44 
1.36 
1.32 
1.44 

.0 

.06 

.24 

.28 
.0 

.0        1 
.04 

.16       \ 
.19 
.0        J 

Gvmther 

Maronla 

.077 

Shoner 

Easily 

Cows'  Milk. 

Control 

.014 

.05 

.006 

.016 

.02 

.03 

.18 

.04 

Cows'  Milk:   Average  phagocytic  count,  .26;  Index,  .18 

Without  serum  or  milk:  Average  phagocytic  count,  .06;   Index,  .04. 

The  average  indices  for  tlie  milk  and  salt  solution  compared  to  the 
blood-serum  of  the  mothers  for  the  various  organisms  are  as  follows: 


Breast-milk. 

Staphylococcus  Aureus 022 

Gonococcus 025 

Pneumococcus 11 

Tubercle  Bacillus    077 


It  will  be  observed  in  the  above  averages  that  while  the  indices  of  the 
human  milk  exceed  those  of  the  cows'  milk  with  the  first  three  organisms, 
the  index  of  the  control  with  salt  solution  is  greater  than  that  of  human 
milk  for  staphylococcus.  The  degree  of  spontaneous  phagocytosis  is  but 
httle  short  of  that  for  human  milk  with  gonococcus.  The  index  of  human 
milk  for  pneumococcus  is  somewhat  higher  than  that  for  cows'  milk  or  for 
the  salt  solution.  On  the  other  hand,  the  index  of  cows'  milk  for  tubercle 
bacillus  is  greater  than  with  human  milk. 

The  greater  index  of  breast-milk  for  pneumococcus  and  of  cows'  milk 


THE    OPSONIC    CONTENT    OF    BREAST-MILK. BUTLER.  393 

for  tubercle  bacilli  might  suggest  the  presence  of  pathological  opsonins. 
My  results  with  the  tubercle  bacillus  are  practically  the  same  as  those 
obtained  by  Turton  and  Appleton  for  human  and  cows'  milk.  In  another 
series  of  examinations  with  pneumococcus,  I  found  a  greater  phagocytosis 
with  cows'  milk  and  salt  solution  than  with  human  milk. 

The  slight  differences  found  in  the  above  indices  between  the  milk  of 
normal  mothers  and  cows'  milk  with  the  organisms  examined  cannot  be 
taken  into  consideration  in  estimating  their  relative  opsonic  power,  which 
latter  does  not  appear  to  be  any  greater  than  that  obtained  with  physiolog- 
ical salt  solution,  with  wliich  the  emulsion  of  bacteria  is  made. 


Investigacion  del   Poder  Opsonico  de  la  Leche  Humana  con  Relacion 
al  Bacilo  de  la  Tuberculosis. — (Butler.) 
Examen  de  la  leche  materna  en  mujeres  normales  para  descubrir  las 
opsoninas.     Comparacion  entre  las  opsoninas  contenidas  en  la  leche  y  en 
la  sangre  de  las  mismas.     Opsoninas  de  la  leche  de  vaca. 


Recherche  sur  le  Pouvoir  Opsonique  du  lait  de  Femme  Centre  le  Bacille 
de  la  Tuberculose. — (Butler.) 
Analyses  du  lait  de  femme  normales  pour  constater  la  presence  d'opso- 
nines.     Comparison  du  contenu  opsonique  de  leui'  sang  avec  celui  de  leur 
lait.     Les  opsonines  dans  le  lait  de  vache. 


Priifung  der   opsonischen  Kraft  der  Muttermilch  fur  Tuberkelbazillen. 

— (Butler.) 
Opsonische    Untersuchungen    von    normaler    Muttermilch.     Vergleich- 
weise  Untersuchung  des  opsonischen  Indicis  des  Bluts  und  der  Milch  von 
normalen  Miittern.     Die  Opsonine  der  Kuhmilch. 


SECTION  IV. 


Tuberculosis    in    Children — Etiology,    Prevention, 
and   Treatment    {Continued). 


SECOND  DAY.    MORNING  SESSION. 
Tuesday,  September  29,  1908. 

MILIARY  TUBERCULOSIS.     TUBERCULOUS  MENINGITIS. 
LOCALIZATION  OF  TUBERCULOSIS  IN  CHILDREN. 

The  President,  Dr.  Jacobi,  called  the  Section  to  order  at  ten  o'clock. 


REPORT    OF    A    CASE    OF   MILIARY  TUBERCULOSIS, 

PROBABLY  OF   BOVINE  ORIGIN,  IN  A  CHILD, 

AGED  FOUR  AND  ONE-HALF  MON^fHS. 

By  Edgar  M.  Green,  M.D.,  and  A.  L.  Kotz,  M.D. 


We  report  this  case  of  acute  miliary  tuberculosis  in  an  infant  because  we 
feel  it  is  interesting  from  the  fact  that  it  seems  to  be  of  bovine  origin,  es- 
tablishes clearly  the  time  of  infection,  and  also  period  required  to  develop 
fully  in  the  child.  Our  objects  are  to  furnish  an  example  of  the  transmis- 
sibility  of  bovine  tuberculosis  to  the  human  being,  and  to  show  that  the 
attack  may  be  acute  and  the  disease  may  be  transmitted  to  the  human  being 
when  there  is  but  one  cow  suffering  from  tuberculosis  in  a  herd  of  ten  or 
twelve  cattle.  Milk  from  high-bred  cattle  may  be  particularly  dangerous, 
and,  even  from  dairies  which  are  clean  and  well  cared  for,  an  infection  may 
occur,  unless  such  cattle  are  most  constantly  watched,  inspected,  and  tested 
with  tuberculin. 

The  history  of  the  case  is  as  follows: 

Female  child,  born  December  3,  1907.  Mother  was  able  to  nurse  the 
child  for  only  two  weeks.  During  this  period  the  child  lost  in  weight,  its 
weight  at  birth  having  been  7  pounds  2  ounces.  At  the  end  of  this  period 
the  child  was  placed  upon  modified  milk  obtained  from  a  herd  of  Jersey 

394 


Photo-micrograph  of  pancreas  showing  disintegration  of  organ  l)y  rea-son  of  caseation. 


-^ 


/"'■ 


'      N  V 


Pancreas.     Margin  of  necrotic  area,  showing  fragments  of  epitheUoid  ct^lls  and  tubercle 

l)a<'illi. 


MILIARY  TUBERCULOSIS  (bOVINE)  IN  AN  INFANT. — GREEN  AND  KOTZ.       395 

COWS.  The  number  of  bacteria  shown  by  examination  of  this  milk  was  3000 
to  6000  per  cubic  centimeter.  This  milk  was  used  during  the  next  two 
weeks,  when  milk  was  obtained  from  a  dairy  of  ordinary  cattle  furnishing 
certified  milk.  The  number  of  bacteria  per  cubic  centimeter  averaged  4000 
to  8000.  The  child  soon  improved  and  continued  gaining  in  weight,  the 
weight  curve  being  exactly  parallel  with  the  normal  curve  until  the  com- 
pletion of  the  twelfth  week.  The  child  now  began  losing  weight;  bowels 
became  loose;  stools  frequently  acid  and  fermented.  The  abdomen  soon 
became  enlarged,  flesh  was  lost  rapidly,  temperature  ranging  between  99° 
and  100°  F.  This  loss  in  weight  continued  uninterruptedly,  although  the 
stools  became  quite  normal  in  consistence  and  quality.  Death  occurred  at 
the  age  of  four  and  one-half  months. 

Autopsy:  Body  of  female  infant  extremely  wasted,  abdomen  much 
distended,  skin  tense.  No  enlarged  glands  to  be  seen.  Incision  revealed 
great  wasting  of  abdominal  muscles  and  adhesion  of  abdominal  contents  to 
anterior  abdominal  wall;  no  fluid  in  abdomen;  in  fact,  abdominal  cavity 
obliterated.  Om.entum  largely  infiltrated  with  tubercles;  stomach  distended 
and  greater  curvature  directed  forward  and  lying  just  under  abdominal  wall. 
Pancreas  superficially  located  and  covered  with  adhesions  which  it  was  im- 
possible to  break  up.  Small  curvature  of  stomach  largely  studded  with 
tubercles.  Peritoneum  covering  spleen  thickened  and  fully  studded  with 
tubercles.  Kidneys  apparently  free  from  involvement.  Mesenteric  glands 
fully  infiltrated  and  almost  all  parts  of  peritoneum  involved.  Liver  possibly 
somewhat  involved.     Mediastinal  glands  much  involved. 

Microscopical  examination  of  the  tubercular  foci  showed  that  they  were 
fused  into  flat,  yellowish  masses  the  size  of  a  lentil.  None  of  the  tubercles 
were  larger  than  this,  and  uniformity  of  size  was  a  remarkable  characteristic. 
In  the  pancreas  these  masses  were  numerous,  completely  disorganizing  the 
viscus.  This  is  a  rare  condition,  as  the  pancreas  is  said  to  seldom  be  in- 
volved in  tuberculosis  of  the  abdomen.  In  the  intestines  the  tubercles  were 
entirely  confined  to  the  serous  and  subserous  coats,  and  these  were  com- 
pletely packed  with  tuberculous  deposits.  Muscular  layers  and  mucosa  were 
atrophied  with  small-celled  infiltration.  The  tubercular  masses  consisted 
of  lymphoid  and  epithelioid  cells  surrounding  small  foci  of  coagulation 
necrosis,  with  very  rarely  giant-cells  present.  The  tubercle  bacilli  were 
most  abundant  in  the  epithelioid  layer  and  on  the  outer  surface  of  the  ne- 
crotic foci.  They  were  absent  in  the  necrotic  tissue  and  near  the  giant-cells. 
Most  of  the  bacilli  were  shorter,  thicker,  and  less  beaded  than  the  ordinary 
bacilli  found  in  human  tissue. 

This  agrees  with  the  investigation  and  measurements  made  by  Theobald 
Smith  and  published  in  the  "Journal  of  Experimental  Medicine,"  in  which 
he  says  that  bovine  bacilli  measure  from  1  to  IJ  micromillimeters,  while  the 
sputum  bacillus  measures  from  H  to  frequently  2  micromillimeters.* 

The  cliild's  paternal  grandmother  died  of  tuberculosis  many  years  ago; 
one  paternal  uncle  also  died  of  tuberculosis  three  or  four  years  ago  in 
the  same  house  where  this  child  was  born.  The  house  was  thoroughly 
fumigated  after  the  death  of  this  uncle.  The  mother  of  the  child  is  well  and 
has  been  for  some  time;  she  has  no  history  of  tuberculosis;  in  fact,  after  the 
*  Theobald  Smith,  in  the  Journal  of  Experimental  Medicine. 


396  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

death  of  the  child,  careful  physical  examination  revealed  no  signs  of  any 
tubercular  disease.  The  father  is  also  well  and  apparently  free  from  disease 
of  any  sort.  No  member  of  the  household  in  which  the  child  was  born  and 
died  has  shown  any  signs  of  tubercular  disease,  nor  has  there  been  any 
previous  case  of  tuberculosis  except  those  mentioned.  The  dairy  farms 
from  which  milk  was  procured  were  next  investigated.  It  was  found  that 
the  first  farm  from  which  milk  w^as  obtained  had  a  herd  of  ten  or  twelve 
cattle;  one  of  these  cows,  some  time  after  the  milk  was  obtained  for  this 
child,  was  found  to  be  infected  with  tuberculosis  and  was  promptly 
slaughtered.  The  second  dairy  from  which  milk  was  obtained  for  a  long 
period  is  a  larger  herd,  having  from  forty  to  sixty  cows.  Examination  of 
the  cattle  in  June  of  this  year,  two  months  after  the  death  of  this  child, 
showed  that  three  cattle  showed  some  symptoms  of  tuberculosis.  They 
were  slaughtered,  but  none  of  them  were  found  infected  in  the  slightest 
degree.  All  of  this  would  seem  to  indicate  that  infection  came  from  the 
first  dairy,  and  that  the  child  acquired  tuberculosis  during  the  third  and 
fourth  weeks  of  its  life  from  this  milk. 

A  few  of  the  interesting  points  shown  by  this  case  are :  First,  the  certainty 
of  primary  infection  through  the  intestines,  and  hence  to  the  peritoneum 
and  the  abdominal  organs,  which,  according  to  Holt,  is  unusual;  second, 
marked  involvement  of  the  pancreas  with  practical  destruction  of  that  organ; 
third,  the  progress  of  the  disease  clearly  shows  gravitation  toward  the  lungs. 
There  were  one  or  two  small  foci  found  in  the  upper  portion  of  the  lower  lobe 
of  the  left  lung,  which  seems  to  indicate  that,  in  an  infection  of  bovine  origin, 
although  the  disease  originates  in  the  abdominal  cavity,  it  nevertheless  tends 
toward  development  in  the  pulmonary  organs.  There  was  no  ulceration  of 
the  mucous  membrane,  which  explains,  perhaps,  the  fact  that  tubercle  bacilli 
were  not  present  in  the  stools.  Most  authorities  agree  that  the  finding  of 
tubercle  bacilli  in  the  stools  is  the  chief  point  in  the  positive  diagnosis  of 
tuberculosis  of  the  intestines.  However,  inasmuch  as  tubercle  bacilli  are 
known  at  the  time  of  infection  to  pass  through  normal  mucous  membrane  of 
the  intestine,  possibly  they  may  gain  exit  in  the  same  way. 

Uffenheimer*  describes  an  interesting  case  of  abdominal  tuberculosis  in 
which  autopsy  revealed  findings  characteristic  of  tuberculosis  in  cattle. 

"The  patient  was  a  year-old,  emaciated,  rachitic  child,  who  suffered  from 
obstinate  constipation.  What  first  struck  the  examiner  was  the  large  and 
prominent  abdomen,  which  on  percussion  was  everywhere  tympanitic,  though 
palpation  revealed  a  few  hard,  deep-seated  nodules.  The  liver  and  spleen 
were  both  enlarged.  The  child  died  soon  after  the  first  examination,  with 
symptoms  of  tuberculous  meningitis.  The  anatomical  findings  were  as 
follows:  Tuberculosis  of  the  mesenteric  glands  and  peritoneum  in  the  form 
of  'perlsucht';  mihary  tuberculosis  of  the  liver,  spleen,  lungs,  and  brain; 
bronchopneumonia;  hydrocephalus;  caries  of  the  metacarpusof  the  left  hand." 

*  Munch,  med.  Wochschr.,  July  18,  1905. 


Small  Intestine.  1,  Miu-osa,  caUinliul.  2,  Submucosa,  hyperplastic.  3,  Int. 
musciilaris  slightly  infiltrated.  4,  Ext.  muscularis  intensely  infiltrated.  5,  Serosa  and 
Suhserosa,  tubercular  deposit.s  and  necrotic  areas. 


Small  Intestine.  1,  Mucosa,— catarrhal  atrophy.  2,  Submucosa,— hyperplastic. 
3,  Int.  muscularis,— slightly  infiltrated.  4,  Ext.  mu.scularis,— intensely  infiltrated, 
o  Serosa  and  Subserosa,— tubercular  deiMisits  ami  necrotic  areas. 


MILIARY  TUBERCULOSIS    (bOVINE)  IN  AN  INFANT. — GREEN  AND  KOTZ.     397 

"The  small  intestine  was  dotted  with  nodules  varying  from  the  size  of  a 
seed  to  that  of  a  pea,  grayish-red,  confluent  in  some  places,  and  soft.  The 
nodules  lay  in  the  submucosa,  which  was  easily  separated  from  the  under- 
lying mucous  membrane." 

"Microscopical  examination  of  the  nodules  showed  a  necrotic  center  con- 
taining a  few  tubercle  bacilli,  an  inner  layer  of  cellular  connective  tissue,  with 
a  few  great  cells  and  an  outer  layer  of  small  round  cells.  The  mesenteric 
glands  were  enlarged  and  caseated." 

"The  writer  believes  this  to  be  a  case  of  primary  abdominal  tuberculosis 
with  secondary  lesions  in  the  lungs  and  other  organs.  The  child's  father 
suffered  for  many  years  from  pulmonary  tuberculosis,  and  it  is  likely  that 
milk  contaminated  by  sputum  was  the  source  of  infection." 

In  conclusion,  it  might  be  asked.  Is  it  possible  that  the  danger  from 
tubercular  infection  from  milk  is  greater  than  the  supposed  or  apparent 
danger  which  comes  from  the  use  of  pasteurized  or  sterilized  milk? 

Fischer*  shows  that  frequently  such  foods  produce  gastro-intestinal 
derangement.  Dyspeptic  attacks  rob  the  system  of  food  required  for  the 
nutrition  of  bone,  muscle,  and  other  organic  structures.  When  such  con- 
ditions persist,  poor  foundations  are  formed,  resulting  in  rickets  or  marasmus. 
The  tubercle  bacillus  easily  gains  entrance,  and  secures  a  foothold  that  ulti- 
mately develops  tuberculosis. 

Must  not  our  dairies  be  more  carefully  inspected?  Should  not  the 
opposition  to  the  tuberculin  test  in  cattle  be  overcome?  Must  not  more 
stringent  laws  be  enacted  and  enforced  with  regard  to  the  use  of  infected 
meat? 

Tuberculose  miliaire  chez  un  enfant  de  4  mois  et  demi.  Rapport  de 
I'autopsie. — (Kotz  et  Green.) 
Fille,  nee  decembre  1907.  A  I'age  de  quinze  jours,  elle  a  6t4t  nourrie 
de  lait  de  vache;  a  I'^ge  de  quatre  semaines  on  lui  donnait  du  lait  "certifi^," 
modifie  pour  I'age.  Poids  augmentant  constamment  jusqu'^  I'age  de  12 
semaines,  apres  quoi  diminution  graduelle  du  poids;  moyenne  de  la  temp6ra- 
ture  a  cet  age  99f°  F.,  I'abdomen  tres  etendu;  mort  a  4  mois  et  ^.  Dans  les 
poumons  on  ne  trouva  que  deux  petits  nodules;  une  ou  deux  glandes  m^dias- 
tinales  infectdes.  La  cavite  periton^ale  6tait  completement  obliter(3e,  les 
intestins  fortement  colles  ensemble.  Les  foyers  tuberculeux  consistaient 
d'un  tas  de  tubercules  fusionn^s  en  une  masse  plate  jaunatre,  de  la  grandeur 
d'une  lentille.  Dans  le  pancreas,  ces  masses  ^talent  nombreuses  et  avaient 
modifie  completement  cet  organe.  (Et  le  pancreas  n'est  que  rarement  in- 
fects.) Dans  les  intestins,  les  tubercules  ^taient  limit^s  i\  la  couche  s(5reuse 
et  subs^reuse  et  celles-ci  6taient  occup^s  entiSrement  de  depots  tuberculeux. 
Les  couches  musculaires  et  muqueuses  dtaient  atrophi^es  par  une  infiltra- 
tion compos^e  de  petites  cellules.     Les  masses  tuberculeuses  consistaient 

*  Louis  Fischer,  M.D.,  in  "  Diseases  of  Infancy  and  Childhood.". 


398  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

en  cellules  lymphoides  et  6pith61oides  entourant  de  petits  foyers  de  necrose 
par  coagulation,  rarement  des  cellules  gdantes.  Les  bacilles  de  la  tuberculose 
dtaient  plus  abondants  dans  la  couche  dpithdloiide  et  a  la  surface  extdrieure 
des  foyers  ndcrotiques.  lis  etaient  presqu 'absents  du  tissu  necrotique 
et  pres  des  cellules  geantes.  La  plupart  des  bacilles  etaient  plus  courts, 
plus  gros  et  les  "grains  de  collier"  moins  prononcfe  que  dans  les  bacilles 
ordinaires  trouvds  dans  le  tissu  humain. 

L'investigation  montra  que  la  ferme  d'ou  le  premier  lait  etait  venu, 
avait  eu  une  ou  deux  vaches  infectdes.  Le  lait  "certifie"  provenait  de 
vaches  saines  ordinaires  et  soumises  k  I'inspection;  parmi  ces  dernieres,  on 
n'en  decouvrit  aucune  qui  soit  infectee.  L'enfant  fut  probablement  infecte 
pendant  sa  troisieme  ou  quatricme  semaine  et  d'une  fagon  si  violente,  que 
la  mort  eut  lieu  trois  mois  plus  tard. 


Tuberculosis  Miliaria  en  un  nine  de  cuatro  mesas  y  medio  de  edad. 
Informe  sobre  la  autopsia. — (Kotz  y  Green.) 
Hembra,  nacida  en  Diciembre  de  1907.  A  la  edad  de  dos  semanas  se  la 
alimento  con  leche  de  vacas,  y  a  la  de  cuatro  semanas  con  leche  modificada 
certificada.  Gano  con  regularidad  hasta  las  doce  semanas  de  edad  y  despu6s 
perdio  gradualmente;  la  temperatura  media  fue  de  99|°,  el  abdomen  muy 
distendido;  murio  a  los  4 J  meses  de  edad.  Dos  pulmones  contenian  solo 
dos  nodulos  y  una  6  dos  glandulas  mediastinales  complicadas.  La  cavidad 
peritonial  estaba  obliterada  completamente  y  los  intestinos  completamente 
pegados.  La  fosa  tubercular  consistia  en  una  masa  de  tubdrculos  fundida  en 
una  masa  plana  amarillenta  del  tamano  de  una  lenteja.  En  el  pancreas 
estas  masas  eran  numerosas,  desorganizando  completamente  el  organo. 
Esta  es  una  condicion  rara  (el  pancreas  esta  complicado  muy  pocas  veces). 
En  los  intestinos  los  tuberculos  estaban  confinados  enteramente  a  las  capas 
serosa  y  subserosa  y  estas  estaban  completamente  rellenas  de  depositos  de 
tuberculos.  El  lecho  muscular  y  la  mucosa  estaban  atrofiados  con  pequeiias 
infiltraciones  de  las  celdas.  Las  masas  tuberculares  consistian  de  celdas 
linfoideas  y  epiteloideas  rodeando  la  fosa  menor  de  coagulacion  necrosis. 
Celdas  gigantes  eran  raras.  El  bacilo  tuberculoso  era  mas  abundante  en  el 
lecho  epiteloideo  y  en  la  superficie  externa  de  la  fosa  necrotica.  Casi  no 
existan  en  el  tejido  necrotico  y  cerca  de  la  celdas  gigantes.  La  mayor  parte 
de  los  bacilos  eran  mas  cortos,  mds  gruesos  y  menos  unidos  unos  con  otros  que 
los  ordinarios  que  se  encuentran  en  el  tejido  humano.  Las  investigaciones 
demostraron  que  la  hacienda  de  la  cual  se  obtuvo  la  primera  leche 
habia  tenido  una  6  dos  vacas  infectadas.  La  leche  certificada  venia  proce- 
dente  de  ganado  ordinario  en  salud  entre  el  cual  no  se  encontro  vaca  infectada. 
La  nifia  se  infecto  indudablemente  durante  la  tercera  y  cuarta  semanas  de 
vida,  y  tan  violentamente  que  la  muerte  ocurrio  tres  meses  mas  tarde. 


CLINICAL    MANIFESTATIONS    OF    TUBERCULOUS 

MENINGITIS. 

By  D.  J.  McCarthy,  M.D.,  and  Charles  A.  Fife,  M.D. 

Philadelphia. 


A  study  of  a  large  number  of  cases  of  tuberculous  meningitis  reveals  not 
only  a  wide  variation  in  the  pathological  findings,  but  an  equally  wide  varia- 
tion in  the  clinical  manifestations.  These  may  or  may  not  be  dependent 
upon  each  other. 

Cases  of  tuberculous  meningitis  presenting  identical  lesions  at  autopsy 
may  have  had,  during  life,  an  entirely  different  clinical  picture.  The  con- 
verse of  this  is  also  sometimes  true.  If  we  seek  a  reason  for  these  variations, 
we  may  find  it  in  one  or  more  of  several  factors.  It  may  depend  upon 
minor  changes  in  the  consistency  of  the  exudates,  the  rapidity  in  the  growth 
of  the  tubercles,  the  grade  of  the  internal  hydrocephalus,  the  presence  of 
mixed  infections,  and  the  physical  condition  of  the  patient  and  of  the  cere- 
bral structures  at  the  time  of  the  development  of  the  meningeal  comphcations. 

One  of  the  most  important  of  these  is  the  condition  of  the  patient's 
brain  as  a  result  of  long-continued  tuberculosis  in  other  viscera,  more  par- 
ticularly the  lungs.     This  acts  in  two  ways : 

In  the  first  place,  long-continued  lung  disease  may  be  assumed  to  pro- 
duce immunity  of  the  structure  of  the  body  in  such  a  way  as  to  prevent  the 
implanting  of  the  tubercle  bacilli,  or  if  they  do  obtain  a  lodgment,  to  Umit 
their  growth. 

Secondly,  long-continued  lung  disease  may,  on  the  other  hand,  produce 
not  only  a  general  wasting  of  the  muscular  and  other  tissue,  but  act  in  a  like 
way  upon  the  brain. 

The  presence  of  large  numbers  of  tubercle  bacilli  in  the  urine  and  feces 
of  dying  cases  presumes  the  presence  of  these  bacilli  in  the  general  circula- 
tion. This  is  further  confirmed  by  the  presence  of  small  tubercles  in  the 
liver  and  kidney  in  such  cases.  These  tubercles,  while  present  in  nearly 
all  dying  cases,  are  locaUzed  forms,  and  do  not  represent  the  condition  which 
we  usually  understand  as  miliary  tubercles.  We  may  therefore  assume  a 
certain  acquired  resistance  to  the  development  of  a  general  infection  through 
the  blood.  Looking  at  the  subject  from  this  view-point,  we  must  consider 
meningitis  complicating  advanced  pulmonary  tuberculosis  as  an  accidental 
occurrence.     This  accident  may  be  the  result  of  an  embolic  infection,  such 

399 


400  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

as  occurred  in  the  case  of  unilateral  meningitis  reported  below.  It  may, 
on  the  other  hand,  be  determined  by  mixed  infection  with  other  organisms. 
I  have  seen  cases  of  tuberculous  meningitis  follow  rapidly  after  a  mixed 
septic  infection,  and  have  been  able  to  recover  from  the  meningeal  exudate 
the  mixed  septic  infecting  organism.  The  mixed  infection,  by  lowering  the 
resistance,  permits  of  the  infection  with  the  tubercle  bacillus.  I  have 
known  of  cases  where  the  same  result  followed  a  test  injection  of  tuber- 
culin. One  of  the  cases  reported  below  (H.  Z.)  would  appear  to  show 
that  traumatism  to  the  head  might  be  a  factor. 

The  brain  in  cases  of  marked  wasting  from  long-continued  lung  disease 
shows  evidence  of  long-continued  loss  of  tissue  in  the  atrophy  of  the  cortical 
gyri  and  the  gradual  enlargement  of  the  cerebral  ventricles.  The  space  in 
the  intracranial  cavity  thus  lost  is  replaced  by  a  fluid  within  and  without  the 
brain.  A  very  important  group  of  symptoms  of  tuberculous  meningitis  is 
due  to  the  increased  intracranial  pressure  as  the  result  of  the  distention  of 
the  ventricles  (acquired  acute  internal  hydrocephalus).  The  brain  at  au- 
topsy, where  there  is  no  marked  wasting,  shows  evidence  of  great  pressure. 
The  gyri  are  flattened  against  the  internal  wall  of  the  skull,  and  the  ventricles 
are  found  distended  with  fluid.  This  condition  is  not  always  due  to  the 
blocking  up  of  the  foramen  of  Magendie  and  the  spaces  of  Retzius  at  the  base 
of  the  brain,  but  may  be  ascribed  to  a  disturbance  of  the  circulation  of  the 
choroid  plexus  or  an  actual  inflamed  condition  of  the  choroids  and  the 
ependyma.  In  the  disturbance  of  the  choroid,  the  pathological  condition 
may  be  very  intense.  In  one  of  the  fulminating  cases  there  was  hemorrhagic 
extravasation  filling  up  all  the  interstices  of  the  structure. 

When  there  is  marked  atrophy  of  the  brain  with  a  moderate  or  marked 
distention  of  the  ventricles,  as  the  result  of  advanced  pulmonary  tuber- 
culosis, the  relatively  increased  intracranial  area  gives  sufficient  room  for 
any  enlargement  of  the  brain  due  to  any  inflammatory  process  of  the  brain 
or  the  ependyma.  It  is  not  at  all  surprising  that  in  such  cases  a  marked 
disturbance  of  the  consciousness,  delirium,  headache,  optic  neuritis,  etc., 
should  be  slight  or  entirely  absent. 

The  type  of  meningitis,  and  more  particularly  in  reference  to  its  chron- 
icity,  must  necessarily  be  a  factor  in  the  clinical  picture  presented.  There 
is  a  chronic  low-grade  irritative  pathological  process  present  in  the  meninges 
of  a  large  percentage  of  cases  dying  from  advanced  pulmonary  tuberculosis. 
This  condition  is  manifested  as  a  distinct  roughening  of  the  meninges,  a  loss 
of  normal  luster,  and  under  the  microscope  a  proliferation  of  the  fixed  cells 
of  the  meninges  and  a  thin  layer  of  fibrin.  A  low  grade  of  productive  men- 
ingitis sometimes  develops  on  this  basis,  and  runs  a  very  chronic  course  with 
comparatively  few  of  the  symptoms  of  the  acute  inflammatory  types.  The 
following  division  is  therefore  suggested; 


TUBERCULOUS    MENINGITIS. — MCCARTHY    AND    FIFE.  401 

(A)  Cases  of  tuberculous  meningitis  which  occur  as  an  accidental  in- 
fection from  a  primary  focus,  the  bone  or  the  glandular  system,  while  the 
patient  is  in  relatively  good  nutrition,  before  wasting  has  occurred,  and 
when  the  system  is  relatively  free  from  the  effects  of  the  tubercle  bacillus 
or  the  mixed  infections. 

(B)  Wide-spread  cases  of  tuberculous  meningitis  complicating  advanced 
pulmonary  tuberculosis  with  wasting  of  the  general  tissues  and  associated 
wasting  of  the  central  nervous  system. 

(C)  Cases  of  tuberculous  meningitis  complicating  pulmonary  tuberculosis 
with  mixed  infections. 

(D)  Tuberculous  meningitis  as  a  local  manifestation  of  acute  miliary 
tuberculosis. 

It  is  not  the  purpose  of  this  paper  to  describe  in  detail  the  symptomat- 
ology of  the  common  forms  of  tuberculous  meningitis.  The  clinical  picture 
of  a  typical  case  occurring  in  childhood  offers  no  difficulty  in  diagnosis.  The 
stage  of  apathy  or  invasion,  the  stage  of  irritation,  the  stage  of  paralysis  and 
coma,  together  present  a  sufficiently  clear  picture,  already  fully  described. 

The  following  irregular  forms  will  alone  be  considered : 

Meningitis  as  a  Local  Manifestation  of  Tuberculous  BACTERiEivnA. 
In  this  form  of  tuberculous  meningitis  the  symptoms  may  be  entirely 
masked  by  a  general  typhoidal  condition  due  to  an  intense  toxemia,  as  a 
result  of  a  blood  infection.  As  in  many  typhoidal  conditions,  delirium 
superv^enes  early  and  the  headache  and  irritative  symptoms  are  masked  in 
such  a  way  as  to  be  frequently  overlooked.  Evidence  of  internal  hydro- 
cephalus is  usually  present  in  such  cases,  and  too  much  attention  cannot 
be  paid  to  irregular  fleeting  palsies,  particularly  of  the  eye  muscles.  When 
pressure  from  hydrocephalus  is  sufficiently  marked,  the  pupils  become  widely 
dilated  and  blindness  supervenes.  An  ophthalmoscopic  examination  may 
show  low-grade  changes  in  the  optic  nerves.  Much  stress  is  laid  in  most  text- 
books on  the  presence  of  miliary  tuberculosis  of  the  choroids,  but  as  a  matter 
of  practical  experience  they  are  of  little  value  on  account  of  their  infrequency 
as  clinical  phenomena.  A  diagnosis  in  such  cases  can  be  made  only  when  the 
physician  keeps  before  him  the  fact  that  stuporous  conditions  and  low-grade 
deliriums  complicating  tuberculosis  should  always  be  considered  suspicious 
of  meningeal  involvement. 

Mixed  Tuberculous  and  Septic  Meningitis. 
This  condition,  of  relatively  rare  occurrence  in  childhood,  is  of  much  more 
frequent  occurrence  in  adult  life,  and  as  such  is  much  more  likely  to  com- 
plicate pulmonary  tuberculosis  than  either  bone  or  glandular  tuberculosis. 
In  these  cases  the  breaking-down  of  the  living  tissue  is  induced  by  some 


402  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

saprophytic  organism.  The  mixed  infecting  agent  may  act  as  the  deter- 
mining factor  in  lowering  the  resistance  of  the  meninges  to  the  infecting 
point  for  the  invasion  of  the  tubercle  bacillus.  The  result  is  a  mixed  type 
of  meningitis  in  which  there  is  present  not  only  tubercles,  but  also  a  semi- 
purulent  exudate  beneath  the  meninges.  The  clinical  picture  presented  in 
such  cases  is  best  illustrated  by  the  following  case : 

E.  S.,  aged  sixteen  months;  parents  healthy;  paternal  grandfather  died 
of  tuberculous  laryngitis,  two  paternal  uncles  died  of  tuberculous  laryngitis, 
and  two  paternal  uncles  of  pulmonary  tuberculosis.  Maternal  history  nega- 
tive. Patient  was  the  second  child.  The  first  child  is  now  four  years  of 
age,  and  although  never  very  robust,  had  no  severe  illness  except  an  attack  of 
gastro-enteritis.     At  present  she  shows  no  signs  of  tuberculosis. 

E.  S.  was  breast-fed  for  five  months;  after  this  with  modified  milk  mix- 
tures. Supply  of  milk  from  only  two  sources.  After  several  months'  feed- 
ing from  first  supply,  milk  was  suspected  and  examined.  It  was  found  to 
contain  saltpetre.  Second  supply  was  from  small  dairy  farm  which  was  not 
under  any  special  governmental  or  society  regulation. 

The  child  was  strong  and  active  until  the  eleventh  month,  when  she 
developed  bilateral  tonsillitis,  followed  by  bilateral  cervical  adenitis.  The 
glands,  however,  did  not  break  down,  but  in  six  weeks  were  so  much  reduced 
that  they  became  scarcely  palpable.  The  tonsillitis  was  associated  with  a 
moderate  bronchitis.  The  lungs  on  careful  examination  gave  no  evidence 
of  tuberculosis.  A  mild  grade  of  gastro-enteritis  was,  however,  present. 
During  the  attack  the  range  of  temperature  was  high,  reaching  104°,  and  the 
leukocytes  were  22,000.  Recovery  was  slow,  but  within  six  weeks  the  child 
seemed  to  be  in  normal  condition. 

About  the  first  of  July  the  child  had  a  mild  attack  of  gastro-enteritis, 
with  a  slow  convalescence;  in  fact,  she  never  regained  her  former  health, 
although  the  stools  became  normal  in  number  and  character. 

There  w^as  no  eruption  of  teeth  until  the  eleventh  month  (at  the  time  of 
the  attack  of  tonsillitis,  etc.),  when  four  teeth  appeared;  then  not  again  until 
the  attack  of  gastro-enteritis  in  July  (fifteenth  month),  when  there  was  an  erup- 
tion of  two  more  teeth.  About  the  5th  of  August  the  gums  again  became 
sore,  and  there  was  a  third  attack  of  enteritis,  which,  however,  was  not  of 
a  grave  nature,  only  three  or  four  movements  a  day,  containing  small  curds 
and  mucus,  of  a  greenish  color,  but  very  offensive  odor.  Temperature  was- 
about  100°  in  the  evenings  and  normal  in  the  mornings.  The  child  seemed 
bright,  had  a  fairly  good  appetite,  but  lost  in  weight.  She  had  no  cough,  and 
although  the  intestinal  condition  apparently  soon  became  normal,  her  gen- 
eral condition  did  not  greatly  improve.  There  was  continuous  loss  of  weight, 
and  a  rise  of  temperature  during  the  afternoon.  About  the  1st  of  August 
the  digestive  symptoms  again  became  pronounced,  there  was  some  vomiting, 
diarrhea,  flatulency.  The  child  became  peevish  and  restless,  and  she  cut 
another  tooth.  Frequent  examination  of  the  chest,  throat,  and  abdomen 
revealed  nothing.  Joints  negative,  no  symptoms  of  brain  or  spinal  cord 
disease,  ears  and  eyes  negative,  no  ophthalmological  examination.  Fever 
continued;  leukocyte  count  made  about  this  time  was  10,250.  Differential 
count  showed  nothing  abnormal.     Stools  gave  evidence  of  fat  indigestion. 


TUBERCULOUS   MENINGITIS. — MCCARTHY   AND   FIFE.  403 

No  tubercle  bacilli  found,  although  several  examinations  of  the  stools  were 
made.  Widal  test  was  negative.  About  the  18th  of  August  the  spleen  be- 
came easily  palpable,  but  remained  so  only  about  a  week,  the  Widal  test 
remaining  negative.     Von  Pirquet  test  also  negative. 

August  18th  the  child  began  to  be  slightly  drowsy,  the  drowsiness  in- 
creasing until  the  27th,  when  the  stupor  was  complete.  There  was  no 
rigidity  until  the  27th,  and  then  only  evident  in  the  neck.  There  was  no 
symptom  referable  to  the  cranial  nerves  until  the  30th,  when  the  pupils 
showed  a  slight  inequality,  and  a  slight  strabismus  of  the  right  eye  was 
present  for  one  day.  There  was  less  motion  of  left  arm  and  leg  than  of  right 
extremities.  The  child  continued  to  swallow  well  until  the  evening  of  the 
31st.  Kernig's  sign  was  present  after  the  30th,  but  not  marked.  Vaso- 
motor instability  present  after  the  29th.  Vomiting  was  not  present  during 
the  entire  illness  except  on  two  occasions,  and  then  was  not  marked  nor  of 
the  cerebral  type.  The  abdomen  was  not  only  not  contracted,  but  was  very 
flaccid.  The  left  kidney  seemed  slightly  larger  than  the  right,  and  at  one 
examination  was  larger  than  at  any  other  time.  Frequent  examinations 
of  the  urine  were  made,  and  although  a  few  leukocytes  were  found,  no 
intermittent  discharge  of  pus  could  be  detected.  Left  pyelonephrosis  was 
suspected. 

The  temperature  was  of  the  septic  type  during  the  last  two  weeks  of  life, 
was  invariably  high  in  the  afternoons,  and  on  the  last  day  of  life  reached 
107°.  Pulse  was  not  irregular,  full  and  strong,  average  rate  of  about  120. 
Respiration  became  irregular,  approaching  the  Cheyne-Stokes  type,  about 
the  27th  of  August.  During  the  last  four  days  of  life  the  child  had  general 
convulsions  (rather  distinct  twitchings  whenever  disturbed),  more  marked 
on  the  right  side.  Death  occurred  on  the  2d  of  September.  Lumbar 
puncture  was  performed  twice.  Two  fluidounces  of  clear  fluid  were  obtained. 
No  tubercle  bacille  found  in  fluid.  Lymphocytes  predominated.  Cerebral 
symptoms  were  not  relieved  by  "puncture." 

Autopsy  showed  the  body  of  a  child  of  poor  nutrition,  with  poor  muscula- 
ture and  a  very  small  amount  of  superficial  fat.  The  pupils  were  equal  and 
dilated,  and  there  were  marks  of  spinal  puncture  in  the  lumbar  region. 
The  peritoneal  adipose  tissue  is.  diminished;  the  abdominal  thoracic  muscles 
poorly  developed.  The  relative  position  of  the  abdominal,  thoracic,  and 
pelvic  viscera  was  normal.     The  lymphatic  glands  were  not  palpable. 

Left  lung:  The  pleura  covering  the  left  lung  was  perfectly  normal. 
The  left  lung  was  air-bearing,  and  on  section  small  miliary  tubercles  were 
seen  scattered  throughout.  These  tubercles  were  pinhead  in  size,  isolated, 
and  located  in  air-bearing  tissue.  There  was  no  coalescence  of  tubercles 
and  no  evidence  of  tuberculous  caseation  or  pneumonia. 

Right  lung :  On  the  right  side  the  pleura  was  normal  with  the  exception 
of  an  area,  irregularly  circular,  4  cm.  in  diameter  on  the  upper  third  of  the 
posterior  portion  of  the  upper  lobe.  In  this  location  the  pleura  was  adherent. 
The  adhesions  were  firm  and  showed  some  induration.  The  section  of  the 
lung  showed  a  cavity  2  by  3  cm,  immediately  beneath  the  surface,  corre- 
sponding to  the  area  of  pleural  adhesion.  The  walls  of  this  cavity  were 
smooth.  The  cavity  was  empty.  There  was  no  evidence  of  tuberculous 
infiltration  surrounding  this  cavity,  except  toward  the  root  of  the  lung. 
A  column  of  tuberculous  infiltration  with  caseation,  0.5  cm.  in  diameter, 


404  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

extended  from  this  cavity  to  the  root  of  the  lung.  In  the  mediastinal  space 
to  this  position  several  enlarged  peribronchial  glands  were  observed.  These 
were  relatively  of  hard  consistence,  yellow  in  color,  but  revealed  no  caseation. 
The  rest  of  the  right  lung  was  air-bearing,  but  contained,  like  the  left,  scat- 
tered isolated  miliary  tubercles  the  size  of  a  pinhead.  The  liver  contained 
large  numbers  of  isolated  miliary  tubercles  the  size  of  a  pinhead.  The  heart 
and  pericardium  were  normal.  The  spleen  was  slightly  enlarged  and  slightly 
softer  than  normal.  It  contained  large  numbers  of  isolated  miliary  tuber- 
cles 0.5  mm.  in  diameter.  The  kidneys  were  larger  than  normal,  swollen, 
and  brownish-yellow  in  color.  The  left  ureter  contained  a  purulent  fluid. 
The  mucous  membrane  of  the  pelvis  of  the  left  kidney  was  thickened  and 
somewhat  injected.  The  bladder  was  distended  with  clear  fluid,  but  was 
otherwise  normal.  The  mesenteric  glands  were  enlarged  and  congested, 
varying  in  size  from  2  mm.  to  2  cm.  in  diameter.  In  one  group  the  mesenteric 
glands  were  not  only  enlarged,  but  were  yellow  in  appearance  and  showed 
on  section  extensive  caseation.  The  retroperitoneal  glands  showed  no  evi- 
dence of  tuberculosis. 

There  was  a  large  quantity  of  turbid  fluid  at  the  base  of  the  brain  and 
in  the  ventricles.  The  convolutions  were  swollen  and  flattened  against  the 
dura.  The  inner  surface  of  the  dura  was  smooth.  There  was  no  evidence 
of  inflammatory  process  except  around  the  foramen  of  Magendie.  The  con- 
vex surface  of  the  brain  was  anemic,  the  base  markedly  congested,  especially 
the  base  of  the  frontal  lobe,  the  posterior  surface  of  which  was  covered  over 
with  thick  seroplastic  exudate.  This  extended  into  the  fissure  of  Sylvius 
on  either  side,  and  over  the  frontal  lobe,  matting  everything  together  from 
the  optic  commissure  to  the  medulla.  At  the  base  of  the  frontal  lobe  ante- 
riorly were  many  scattered,  yellowish,  gelatinous,  white  tubercles,  and  in 
fairly  large  numbers  along  the  vessels  on  the  lateral  surface  of  the  frontal 
and  temporosphenoidal  lobes.  No  isolated  tubercles  were  to  be  seen  on  the 
above-mentioned  exudate,  even  on  the  vellum  interpositum,  but  were  to 
be  seen  on  the  choroid  plexus.  Cerebellum  was  perfectly  clear.  There  were 
no  tubercles.     There  were  relatively  few  tubercles  on  the  convexity. 

Microscopical  Examination. — Right  lung:  Sections  through  the  cavity 
showed,  in  the  immediate  neighborhood  of  the  cavity  wall,  a  few  coalescing 
tubercles  of  typical  appearance;  there  was  marked  distention  of  the  blood- 
vessels and  the  presence  of  some  free  blood  in  the  tissues.  The  peribron- 
chial glands  showed  marked  fil^rosis  at  the  periphery  and  caseating  tubercles 
in  the  center  of  the  gland.  The  kidneys  showed  a  marked  grade  of  paren- 
chymatous nephritis.  Tubercles  were  not  seen  in  the  sections.  The  brain 
showed  a  productive  type  of  leptomeningitis  on  the  convexity,  with  iso- 
lated miliary  tubercles  here  and  thei*e,  and  an  extensive  seroplastic  tubercu- 
losis at  the  base  of  the  brain,  with  large  areas  of  caseating  tubercles.  Both 
processes  indicated  a  chronic  subacute  process,  the  more  chronic  of  these 
being  on  the  convexity. 

This  case  appears  to  us  to  be  worthy  of  record  on  account  of  the  possible 
intestinal  source  of  infection,  the  presence  of  cavity  formation  evidently  of 
some  standing,  in  the  lungs  of  the  child,  the  rather  chronic  type  of  tubercu- 
lous meningitis,  and  the  problem  of  diagnosis  of  tuberculous  meningitis 


TUBERCULOUS   MENINGITIS. — MCCARTHY   AND   FIFE.  405 

with  comparatively  few  symptoms  relative  to  the  nervous  system  and  no 
symptoms  at  all  referable  to  the  pulmonary  system,  and  with  evidence  of  a 
pyelonephritis.  From  a  clinical  standpoint,  the  patient  did  not  at  any  time 
present  symptoms  of  tuberculosis.  There  was  no  cough,  no  dyspnea,  and 
only  the  general  wasting,  which  might  be  attributed  to  the  complicating 
kidney  condition.  Until  two  days  before  death,  there  was  no  suspicion  of 
a  tuberculous  meningitis. 

The  microscopical  examination  showed  that  the  meningeal  process  must 
have  existed  for  some  time.  Judging  from  experience  with  the  histo- 
logical pictures  of  other  cases,  it  must  have  been  a  matter  of  several  weeks. 
The  child  showed  some  irritability,  but  no  more  than  that  seen  in  teething 
children.  There  was  some  stupor  for  seven  or  eight  days  preceding  death. 
This  was  not  of  considerable  importance  on  account  of  the  weakened,  wasted 
condition  of  the  child.  The  temperature  was  of  a  septic  type;  the  pulse- 
rate  was  high,  contrary  to  the  general  rule.  The  patient  was  seen  by  three 
prominent  specialists  in  children's  diseases,  who  after  a  careful  examination 
did  not  suspect  either  the  pulmonary  or  the  nervous  condition. 

The  explanation  of  the  lack  of  symptoms  referable  to  the  nervous  sys- 
tem, not  only  in  this  but  in  other  cases,  will  receive  much  fuller  consideration 
in  another  paper  presented,  by  one  of  us  (D.  J.  M.),  in  this  Section  of  the 
Congress.  It  is,  however,  worth  while  to  call  attention  to  the  fact  that  active 
types  of  tuberculous  meningitis  may  run  a  much  longer  course  with  the 
symptoms  referable  to  the  nervous  system  entirely  masked,  where 
pulmonary  or  other  septic  complicating  conditions  exist.  It  is  questionable 
whether  in  this  case  it  was  possible  to  make  a  diagnosis  of  tuberculous 
meningitis  before  the  development  of  convulsions,  immediately  before 
death,  and  more  particularly  when  the  diagnosis  of  mihary  tuberculosis  was 
not  made.  There  is  no  question,  in  view  of  the  autopsy  findings,  that  the 
pulmonary  condition  should  have  been  diagnosed  by  a  careful  examination, 
and  yet  this  was  entirely  overlooked  by  specialists  of  high  repute,  who 
examined  the  lungs.  If  this  diagnosis  had  been  made,  the  general  rule 
which  experience  has  taught  us,  that  a  progressively,  deepening  stupor, 
complicating  tuberculosis  of  the  lungs  or  other  viscera  should  suggest 
tuberculous  meningitis,  even  in  the  absence  of  all  other  symptoms,  would 
probably  have  led  to  a  proper  conclusion. 

One  of  the  above  cases  at  the  Phipps  Institute,  No.  3152,  although  under 
careful  observation  of  several  physicians,  did  not  present  at  any  time  any 
symptoms  of  meningitis.  He  was  a  case  of  advanced  pulmonary  tubercu- 
losis with  laryngeal  involvement.  There  was  intense  dyspnea  for  some 
time  before  death.  The  patient  at  no  time  complained  of  headache,  did  not 
present  contraction  of  the  neck  or  cranial  nerve  palsies,  and  yet  at  autopsy 
there  was  an  extensive  productive  type  of  meningitis,  not  only  at  the  base 


406  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

of  the  brain,  but  extending  over  the  convexity.  Between  the  gyri  there 
was  a  large  number  of  cells  of  spindle  type  with  elliptical  nuclei  with  some 
round  cells.  There  were  no  distinct  localized  tubercles  in  this  case,  and  no 
exudate  over  the  base  of  the  brain  other  than  the  subacute  leptomeningeal 
irritation  above  noted. 

A  probable  example  of  the  healing  type  of  cases  was  that  of  a  girl  which 
occurred  at  the  PMladeliDliia  Hospital.     This  case  was  as  follows : 

B.  J.,  female,  aged  forty-six;  color,  black;  birthplace.  North  Carolina; 
occupation,  housework.  Admitted  to  the  Philadelphia  Hospital,  August  18, 
1908. 

Patient  was  in  a  semistuporous  condition,  unable  to  answer  questions 
intelligently;  so  no  subjective  test  could  be  obtained.  A  well-developed, 
fairly  well-nourished  adult  negro  female. 

Expression  is  vacant  and  distant.  Divergent  strabismus,  amaurosis. 
Pupils  are  unequal,  the  left  measuring  4  mm.  and  the  right  3  mm.  They  are 
irregular  to  a  marked  degree  and  react  very  slightly  and  sluggishly  to  light, 
accommodation,  and  convergence.  Eye-grounds  were  reported  negative 
by  chief. 

Tongue  dry,  coated,  protrudes  centrally  and  shows  tremor.  There  is  a 
foul  odor  on  the  breath. 

Pulse  is  rapid,  low  volume,  and  tension  regular  and  synchronous. 

Head  is  retracted  and  rigid.  The  muscles  of  the  back  of  the  neck  are  very 
rigid.  There  are  slight  convulsive  contractures,  clonic  in  type,  in  all  parts 
of  the  body. 

Chest  is  emaciated,  supraclavicular  and  infraclavicular  fossae,  and  inter- 
spaces are  prominent.  The  chest  movements  are  very  shallow  and  equal. 
There  is  impairment  of  resonance  in  the  first  and  second  interspaces  ante- 
riorly, with  greatly  roughened  breath  sounds  and  some  increase  in  vocal  and 
tactile  fremitus.  The  area  of  cardiac  dullness  is  increased  to  right  and  to 
left.  It  extends  to  the  midsternal  line  to  a  point  \  to  the  right  of  the  nipple 
line.  There  is  a  rough,  harsh,  presystolic  murmur  heard  at  the  apex  and 
not  transmitted.  There  is  a  distinct  thrill  at  the  apex.  Myocardial  tone 
fair.     A  distinct  "bucket  sound"  is  heard  over  the  aortic  area. 

Abdomen  is  hard  and  tense  and  shows  some  tympanites.  Organs  appear 
normal. 

Glands:  The  inguinal  glands  are  moderately  enlarged,  but  the  cervical 
glands  are  very  markedly  enlarged. 

Extremities  show  scars  which  are  suspicious  of  syphilis. 

Muscles  are  well  developed  and  show  no  atrophy.  Fibrillary  tremors  are 
seen,  with  restlessness,  rigidity  of  the  muscles  of  the  neck,  and  in  the  back. 

Reflexes  are  uniformly  increased;  most  marked,  however,  on  the  left  side. 
There  is  retraction  to  plantar  irritation  on  the  left;  slight  flexion  on  the 
right.  There  is  no  patellar  or  ankle  clonus.  Kernig's  sign  is  marked  on 
both  sides.  Test  for  sight  reveals  almost  complete  loss  of  sight.  Eye 
muscles  cannot  be  tested. 

Examination  of  cerebrospinal  fluid:  8  :  21  :  '08.  Tubercle  bacilU  were 
present,  a  few  lymphocytes  and  a  few  polynuclears. 

9  :  22  :  '08.  Cerebrospinal  fluid  acellular  and  contains  no  tubercle  bacilli. 


TUBERCULOUS    MENINGITIS. — MCCARTHY    AND   FIFE.  407 

The  temperature  at  first  was  subnormal,  but  at  times  was  elevated  as 
high  as  99.4°.  The  pulse  ranged  between  90  and  100,  but  was  on  occasions 
as  high  as  120.  The  respiratory  rate  was  somewhat  elevated,  varying 
through  periods  of  irritation  between  25  and  30. 

9:1:  '08.  Patient  is  clearing  up.  Eyesight  is  better,  but  only  recognizes 
large  objects.  Mental  condition  is  clearer.  Kernig's  sign  is  still  present. 
Rigidity  of  the  neck  has  largely  disappeared. 

9  : 4  :'08.     Patient  is  much  better  this  morning,  generally. 

9:5:  '08.     All  meningeal  troubles  have  chsappeared. 

9:11  :  '08.  Patient  is  much  better,  but  is  very  noisy  and  calls  out  very 
loudly  about  all  sorts  of  topics  relating  to  the  Bible. 

9  :  12  :  '09.  A  condition  of  acute  religious  mania  obtains;  no  symptoms 
of  meningitis. 

A  patient  presenting  a  progressive  low  type  of  tuberculous  infection  of 
the  lungs  gradually  manifests,  together  with  wasting  and  cough,  a  liigher  and 
more  irregular  temperature,  with  evidence  of  some  septic  infection.  The 
pulse-rate  is  much  more  rapid  than  is  to  be  expected  in  tuberculosis  of  the 
meninges  at  this  stage,  and  little  attention  is  paid  to  a  slowly  progressing 
stupor  on  account  of  the  illness  of  the  child.  The  exudate  which  is  formed 
at  the  base  of  the  brain  in  these  cases  is  not  of  that  firm  consistency  which  is 
seen  in  productive  types  of  meningitis,  but  is  of  a  looser  semipurulent  type, 
which  produces  relatively  little  damage  by  pressure,  and  to  which  the  cranial 
nerves  offer  more  resistance  than  would  be  expected.  Cranial  nerve  palsies, 
if  they  occur,  are  of  a  very  fleeting  type,  and  if  observed  are  usually  attri- 
buted to  other  causes.  Rigidity  of  the  muscles  of  the  neck  and  Kernig's 
sign  may  not  be  well  developed  and  may  only  occur  late  in  the  course  of  the 
disease. 

Localized  Forms  of  Meningitis. 

Various  forms  of  meningitis  localized  to  certain  definite  areas  of  the 
brain  may  occur  and  give  rise  to  certain  definite  groups  of  symptoms  ex- 
tremely puzzling,  if  the  pathology  is  not  carefully  studied.  In  my  o^vn 
collection  I  have  cases  of  acute  tuberculous  meningitis  localized  (a)  to  the 
mesial  surface  of  the  brain;  (6)  to  the  posterior  fossae;  (c)  to  one  cerebral 
hemisphere;  (d)  to  a  localized  area  on  the  frontal  lobe;  and  (c)  a  large  group 
of  cases  of  a  very  peculiar  nature,  showing  irregular  areas  of  hemorrhagic 
softening,  most  frequently  combined  at  the  base  of  the  frontal  and  temporo- 
sphenoidal  lobes,  which  cannot,  in  the  ordinary  sense  of  the  term,  be  con- 
sidered tuberculous,  but  which  complicate  pulmonary  tuberculosis.  This 
latter  group  of  cases  has  been  dealt  with  from  the  pathological  standpoint 
in  another  paper ;  the  clinical  manifestations  have  not  been  sufficiently  well 
worked  out  as  to  be  of  much  diagnostic  value.  Some  of  the  cases  have,  how- 
ever, been  found  associated  with  certain  mental  changes,  and  may  stand  in 
some  causative  relation  to  such  symptoms. 


408  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

The  localized  forms  of  active  tuberculous  meningitis  may  be  diagnosed 
by  careful  attention  to  the  mode  of  onset  and  the  symptoms  of  localization. 
As  an  example  of  this,  the  case  of  unilateral  tuberculous  meningitis  limited 
to  one  hemisphere,  above  noted,  was  of  sudden  onset,  with  irritative  symp- 
toms (convulsions)  localized  to  the  right  side  of  the  body,  without  loss  of 
consciousness,  and  followed  by  paralysis  limited  to  one  side  of  the  body. 
Inasmuch  as  it  complicated  advanced  pulmonary  tuberculosis,  a  diagnosis 
of  unilateral  tuberculous  meningitis  was  the  only  logical  interpretation  of 
the  sj'mptom-complex. 

In  a  case  of  Frentzel's  the  tuberculosis  was  limited  to  the  choroid  plexus. 
Repeated  spells  of  unconsciousness,  with  contractions  of  the  facial  muscles, 
and  death  in  thirty  hours  were  the  only  symptoms. 

In  tuberculosis  of  the  posterior  fossae,  the  predominance  of  irritative 
symptoms  referred  to  the  cerebellum,  marked  retraction  of  the  head,  with 
persistent  headaches,  but  without  evidence  of  internal  hydrocephalus,  ought 
to  make  a  presumptive  diagnosis. 

In  the  case  of  tuberculosis  restricted  to  the  mesial  surface  of  the  brain, 
the  symptoms  were  very  meager.  The  pupils  were  unequal,  the  left  large 
and  almost  twice  the  size  of  the  right.  Both  reacted  to  light  and  conver- 
gence. There  was  a  shght  tremor  of  the  hands,  which  became  more  accent- 
uated, and  shortly  before  death  became  localized  to  the  right  arm  and  leg 
and  resembled  that  seen  in  paralysis  agitans.  The  muscular  power  was  fair 
for  one  suffering  from  advanced  pulmonary  tuberculosis,  and  reflex  activity 
in  all  the  extremities  was  present.  The  Babinski  reflex  (extension  of  the 
toes  to  plantar  irritation)  was  present  on  the  right  side  and  absent  on  the 
left.  The  same  was  true  of  the  Gordon  paradoxical  phenomenon.  The 
patient  showed  a  marked  failure  of  memory,  but  consciousness  was  preserved 
until  shortly  before  death,  when  terminal  delirium  supervened.  The  only 
symptoms  on  which  a  diagnosis  of  tuberculous  meningitis  could  be  made  in 
tliis  case  were  inequality  of  the  pupils,  evidence  of  perverted  motor  function, 
the  tremor  of  one  side  of  the  body,  and  the  Babinski  reflex. 

Whether  tuberculous  meningitis  ever  goes  on  to  healing  or  not  has  been 
a  much  mooted  question.  One  can  see  no  reason,  from  a  pathological 
standpoint,  why  certain  localized  forms  should  not  get  well.  Tuber- 
culous meningitis  from  a  pathological  standpoint  shows  a  very  varying  pic- 
ture. The  fulminating  cases  may  terminate  fatally  in  as  short  a  period  as 
three  days,  but  other  cases  may  be  prolonged  for  weeks.  In  the  acute  ful- 
minating forms  extravasating  hemorrhage  is  not  at  all  an  infrequent  con- 
dition. In  one  of  the  cases  in  my  collection  extensive  hemorrhages  were 
present  not  only  in  the  pons  and  basal  ganglia,  but  also  filled  up  the  choroid 
plexuses  and  the  interstices  of  the  lateral  ventricles.  In  the  more  chronic 
types  the  type  of  cell  formation  is  such  as  to  lead  us  to  the  conclusion  that  we 


TUBERCULOUS   MENINGITIS. — MCCARTHY   AND   FIFE.  409 

are  dealing  with  intermediate  forms  between  an  acute  inflammatory  proc- 
ess and  a  low-grade  proliferative  process.  The  symptomatology  in  this 
latter  group  is  quite  different  from  that  of  the  acute  type.  Such  an  im- 
portant symptom  as  headache  may  be  entirely  absent.  It  may,  however, 
be  the  only  symptom.  The  temperature  in  these  cases  is  only  slightly 
elevated,  ranging  from  99°  to  100°,  with  a  terminal  rise  to  a  much  higher 
grade.  Where  the  productive  changes  are  wide-spread,  irritative  symptoms, 
such  as  muscular  twitcliings  and  vasomotor  disturbances,  may  occur. 
Symptoms  referred  to  disturbance  of  function  of  the  cranial  nerves  may  be 
entirely  absent.  The  diagnosis  in  such  cases  not  infrequently  remains  in 
doubt  until  the  termination  of  the  case.  It  is  to  be  remembered  that  the 
process  in  such  cases  is  a  diffuse  infiltrating  process  which  can  be  readily 
overlooked  at  autopsy  because  of  the  absence  of  isolated  tubercles.  The 
diagnosis  is  often  in  doubt  until  the  microscopical  examination  has  been 
made. 

In  one  of  the  cases  above  referred  to  under  localized  meningitis,  large 
numbers  of  small  tubercles  composed  of  a  spindle  type  of  cell  and  without 
evidence  of  inflammatory  reaction  in  the  surrounding  meninges,  may  well  be 
considered  as  a  healing  type.  We  are  certainly  not  justified  in  calling  this  a 
healed  case  of  meningitis,  because  there  was  no  inflammation  in  the  true 
sense  of  the  term.  As  a  healed  process,  all  that  would  have  remained  would 
have  been  a  few  pinpoint  white  nodules  on  the  meninges,  which  have  been 
observed  at  times  at  autopsy,  but  which,  on  account  of  there  being  no  evi- 
dence as  to  their  tuberculous  nature,  are  usually  not  considered  as  such. 

Traumatism  and  Tuberculous  Meningitis. 
A  subject  not  only  of  clinical  importance,  but  also  of  distinct  medico- 
legal value,  is  that  group  of  cases  in  which  the  tuberculous  meningitis  follows 
immediately  on  some  injury  to  the  head.     The  following  case  will  illustrate 
the  importance  of  tliis  subject : 

H.  Z.,  aged_^  twenty-one;  color,  white;  birthplace,  Poland;  occupation, 
longshoreman. 

Admitted  to  the  hospital,  August  23,  1908.  Died,  September  11,  1908. 
On  admission  had  nausea,  vomiting,  anorexia,  severe  headache  which  is 
constant,  drowsiness  wliich  frequently  deepens  into  stupor,  and  a  feeling  of 
general  weakness. 

On  Sunday,  August  14,  1908,  as  the  patient  was  at  work  in  a  dock,  a 
large  iron  hook,  six  inches  in  length  and  as  thick  as  one's  wrist,  was  swung 
against  him,  striking  him  in  the  right  parieto-temporal  region.  The  blow 
merely  stunned  him  and  he  did  not  become  unconscious,  but  continued  to 
attend  to  his  duties  throughout  that  day,  suffering  only  from  a  severe  head- 
ache. He  worked  the  next  day,  and  the  following  day,  Wednesday,  August 
17,  1908,  when  he  commenced  vomiting,  and  the  headache  became  more 


410  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

severe.  In  a  few  days  he  became  drowsy.  This  gradually  deepened  into 
stupor,  and  the  patient  has  remained  in  this  condition  ever  since. 

The  patient  states  that  on  Wednesday,  three  days  after  the  accident,  he 
took  a  drink  of  water,  and  immediately  found  that  he  could  not  use  the  right 
arm  and  leg.  On  examination  of  the  right  upper  and  lower  extremities, 
power  is  found  to  be  veiy  good.  They  are  just  as  strong  as  those  of  the 
opposite  side.     There  is  no  evidence  whatever  of  hemiplegia. 

Patient  is  of  medium  height,  well  nourished,  and  very  well  developed 
muscularly. 

He  is  in  a  condition  of  stupor.  When  spoken  to  he  pays  no  attention 
unless  the  question  is  repeated  and  he  is  aroused,  when  he  will  give  a  mono- 
syllabic reply.  He  lies  quietly,  takes  nourishment  well,  and  has  had  no 
convulsions  since  coming  into  the  ward.  On  examination  of  the  head,  a 
slight  depression  is  noted  in  the  right  temporo-frontal  region.  There  is  no 
abrasion  such  as  would  come  from  blunt  force,  and  on  careful  examination 
it  is  found  to  be  in  all  probability  a  normal  depression.  The  one  on  the 
other  side  corresponds,  but  is  not  quite  so  marked. 

The  eyes  react  to  light  and  appear  to  react  to  accommodation.  Con- 
vergence is  good.  Extraocular  movements  are  normal.  There  is  no  exoph- 
thalmus  in  either  eye.     Sclera,  cornea,  etc.,  appear  to  be  in  good  condition. 

Nose  and  throat  are  negative.  Tongue  is  protruded  centrally,  is  clean 
and  free  from  tremor. 

Pulse  is  very  slow,  being  about  50  to  54  beats  per  minute.  Volume  and 
tension  are  rather  poor  and  the  pulsations  are  slightly  irregular.  Radials 
beat  synchronously.     There  appears  to  be  a  slight  arteriosclerosis  present. 

Friction  rub  is  heard  over  the  upper  portion  of  the  left  lung  antero- 
laterally.     Impaired  resonance  is  present  in  the  left  apex. 

Heart  action  is  regular,  of  good  myocardial  tone,  but  is  slow.  No  mur- 
murs are  present.  Abdomen  and  internal  organs  are  apparently  normal. 
The  spine  is  apparently  normal.  A  hydrocele  is  present  on  the  left  side  of 
the  scrotum.     It  is  about  the  size  of  an  orange. 

8  :  26  :  '08.  Examination  of  the  eyes  shows  the  presence  of  a  neuroretinitis 
with  marked  congestion  of  the  veins.  There  is  slight  swelling  of  the  disk, 
more  marked  on  the  right  side.  Pupils  react  to  light,  accommodation,  and 
convergence.  Extraocular  movements  are  good.  No  loss  of  power  or  ataxia 
of  arms  is  present.  Muscular  power,  flexion,  and  extension  are  good.  There 
is  no  ankle  clonus;  knee-jerks  are  normal;  if  anything,  diminished.  Achilles 
jerk  is  normal  on  both  sides.  There  is  flexion  of  toes  to  plantar  irritation 
on  both  sides.  Sensation  is  retained  to  both  pain  and  touch.  The  cranial 
nerves,  with  the  exception  of  the  second,  appear  to  be  normal.  Biceps  jerks 
are  normal.  There  is  a  well-developed  Kernig's  sign  on  the  left  side. 
There  is  a  slight  Kernig's  sign  on  the  right  side.  Patient  complains  of  pain 
in  the  neck  when  head  is  extended.  Slight  rigidity  of  the  neck  is  present. 
On  the  lower  extremities  there  is  a  purplish  mottling,  probably  vasomotor  in 
character.  (Examination  on  a  cold,  damp  day.)  The  same  is  true  of 
the  arms,  which  are  warm.  There  is  a  slight  Gordon  paradoxical  phe- 
nomenon on  the  left  side,  questionable  on  the  right.  There  is  tenderness 
on  the  frontal  area  over  right  eye.  x-Ray  examination  shows  a  depressed 
fracture  of  external  table  of  skull  in  right  fronto-parietal  area. 

9  :2  :'08.   Friction  rub  is  heard  over  upper  portion  of  the  left  lung  antero- 


TUBERCULOUS   MENINGITIS. — MCCARTHY    AND   FIFE.  411 

laterally.  Impaired  resonance  is  present  in  apex  of  left  lung.  There  is 
bronchial  breathing  to  second  interspace  and  to  spine  of  scapula.  Whistling 
pectoriloquy  at  apex. 

9:3  :  '08.  Patient  seems  to  be  in  more  stupid  condition  than  he  was 
yesterday.  Friction  rub  is  still  heard.  There  are  no  rales.  Heart  action 
is  regular,  but  slightly  slower  than  normal. 

9:4:  '08.  Patient's  mental  condition  is  unchanged  this  a.m.  Friction 
rub  is  greatly  diminished.  There  are  no  rales.  Heart  action  is  still  regular 
and  slightly  slowed. 

Urine  report:  Amber  yellow  in  color,  slight  sediment,  alkaline  in  reac- 
tion. Sp.  gr.  1020.  No  albumin  present.  Microscopical  examination: 
There  were  triple  phosphate  crystals,  urates,  few  calcium  oxalates,  and  a 
number  of  epithelial  cells. 

Eye  report  by  Dr.  Halloway :  9  : 2  :  '08 :  Right  pupil  is  slightly  larger  than 
the  left;  both  respond  to  light  and  convergence.  Ocular  movements,  as 
far  as  can  be  determined,  are  9000.  Right:  No  change  in  the  media,  the 
disk  is  slightly  oval  with  blurred  edges  most  marked  above  and  below;  the 
veins  show  some  overfilling;  there  is  no  evidence  of  light  spot  over  disk. 
There  is  no  change  in  choroid  or  retina.  Left:  There  is  no  change  in  the 
media;  disk  is  practically  oval,  with  distinct  blurring  of  the  upper  and  lower 
margins,  the  nasal  and  temporal  margins  being  much  more  distinct.  Down 
and  out  along  the  inferior  temporal  vessels  is  a  vague  and  poorly  defined 
pigment  patch,  which  is  probably  congenital.  Diagnosis:  Beginning  optic 
neuritis,  slightly  more  marked  on  the  right  side. 

The  patient  was  transferred  to  the  surgical  department  September  3, 
1908.  An  osteoplastic  flap  was  made  on  the  left  side  over  the  seat  of  the 
injury  and  the  area  of  bone  depression  as  indicated  by  the  x-ray  examination. 
There  was  no  depression  fracture  found  on  examination  of  the  bone,  and  the 
brain  showed  evidence  of  marked  active  congestion,  was  markedly  swollen, 
and  the  meninges  were  dull  and  lusterless.  The  lateral  ventricle  on  the  left 
side  was  tapped  and  considerable  cloudy  fluid  evacuated.  This  led  to  a 
decrease  of  the  swelling.  The  patient  recovered  from  the  operation,  but 
remained  in  the  same  condition  of  semistupor,  which  gradually  became 
deeper  from  day  to  day  until  death  supervened  on  September  11,  1908. 
Shortly  after  the  operation  a  hemiplegia  developed  on  the  left  side,  which 
was  probably  due  to  the  pressure  of  the  swollen  brain  against  the  margin  of 
the  operation  area  (posterior  edge  of  the  osteoplastic  flap  corresponding  to 
the  Rolandic  area). 

The  autopsy  showed  an  extensive  tuberculous  meningitis  of  seroplastic 
type.  This  was  very  extensive  over  the  base  and  almost  as  extensive  over 
the  convexity,  more  particularly  along  the  margin  of  the  cerebral  hemi- 
spheres. Isolated  tubercles  were  scattered  along  the  vessels  on  the  external 
surface  of  the  hemispheres. 

In  the  above  case  there  was  every  reason  to  believe  that  the  symptoms 
were  due  to  traumatism.  The  symptoms  do  not,  however,  conform  to  those 
of  cerebral  hemorrhage  or  cerebral  concussion.  There  were  no  symptoms 
in  this  case  referred  to  the  cranial  nerves,  with  the  exception  of  changes  in 
the  eye-grounds.     There  were  no  tubercle  bacilli  in  the  cerebrospinal  fluid. 


412  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

There  was,  however,  evidence  of  meningeal  irritation  and  rigidity  of  the  neck, 
with  a  well-developed  Kernig's  symptom,  and  the  presence  of  a  tuberculosis 
of  the  left  lung  led  me  to  make  a  diagnosis  of  tuberculous  meningitis,  but  it 
did  not  seem  justifiable  to  refuse  an  operation  with  an  evidence  of  external 
injury  to  the  skull  and  the  evidence  of  a  depressed  fracture  of  the  skull  at  the 
point  of  injury.  This  decision  was  made  on  account  of  the  hopeless  nature 
of  the  diagnosis  of  tuberculous  meningitis  and  the  possibihty  of  good  from 
an  extensive  decompression  operation. 

The  purpose  of  this  paper  is  to  call  attention  to  the  fact  that  the  diag- 
nosis of  tuberculous  meningitis  must  necessarily  and  primarily  rest  on  the 
discovery  of  the  source  of  infection.  This  necessarily  entails  an  examina- 
tion of  the  entire  body,  and  more  particularly  of  the  lungs.  Wliile  lumbar 
puncture  has  its  value,  it  cannot  be  too  much  relied  upon  in  the  reports  from 
the  laboratories  of  large  hospitals.  In  the  last  case  above  quoted,  the  re- 
port was  negative;  the  diagnosis  was  only  made  by  careful  attention  to  the 
physical  signs  in  the  chest. 

It  should  be  remembered  that  tuberculous  meningitis  complicating  pul- 
monary tuberculosis  may  be  very  extensive  and  3^et  present  few  physical 
signs.  I  have  known  cases  that  presented  no  other  symptons  than  head- 
ache, mental  tardiness,  and  the  Babinski  or  Gordon  phenomenon.  In  other 
words,  the  diagnosis  of  tuberculous  meningitis  does  not  depend  upon  a  mul- 
tiplicity of  symptoms,  following  the  lines  of  the  classical  cases  reported  in 
text-books,  but  on  a  careful  study  of  few  or  many  adventitious  symptoms, 
in  the  course  of  a  glandular  or  pulmonary  tuberculosis.  A  knowledge  of 
the  pathology  of  tuberculosis  of  the  meninges  and  its  relation  to  tubercu- 
losis, in  general,  an  open  mind  for  symptoms  referable  to  the  nervous  sys- 
tem, and  some  experience  with  the  varying  types  as  presented  clinically, 
would  mean  more  in  the  diagnosis  than  the  evidence  to  be  derived  from  a 
text-book  or  the  microscope ;  not  that  the  latter  is  to  be  neglected,  but  it  is 
not  to  be  overvalued. 


Las  Manifestaciones  Clinicas  de  la  Meningitis  Tuberculosa. 

Tuberculosis  Miliar  con  Meningitis  Tuberculosa  enun  Nino  de  17  Mesas  de 
Edad. — (McCarthy  y  Fife.) 

La  meningitis  tuberculosa  como  una  manifestacion  local  de  la  bac- 
teremia tuberculosa. 

Paralisis  transitoria  irregular,  especialmente  de  los  musculos  del  ojo, 
ceguedad  y  dilatacion  de  la  pupila  debido  al  hidrocefalos  interno,  estupor 
y  delirio  ayuda  en  la  distincion  de  estos  casos. 

La  tuberculosis  de  ninos  6  infeccion  septica.  La  afeccion  de  los  nervios 
craneales  en  este  caso  es  muy  limitada,  mas  la  rapidez  del  pulso  se  aumenta. 


TUBERCULOUS   MENINGITIS. — MCCAETHY    AND    FIFE.  413 

Meningitis  tuberculosa  localizada :  esta  debe  distinguirse  de  los  sintomaa 
localizados  de  la  tuberculosis  pulmonar. 

Tipos  productivos  y  cicatrizantes  que  demuestran  pathologicamente 
tuberculos  con  celulas  de  tipo  huso.     Casos  fulminantes  de  hemorragia. 

Casos  asociados  con  tromatismo.  Estos  ultimos  son  de  gran  impor- 
tancia  en  la  Medicina  Legal. 

El  objeto  de  este  articulo  es  Uamar  la  atencion  al  hecho  de  que  el  origen 
de  la  infeccion  debe  ser  descubierta  y  el  diagnostico  del  laboratorio  valuarlo 
como  secundario  en  importancia. 

Este  caso  es  de  un  nino  de  17  meses  de  edad  en  el  cual  se  presento  un 
ataque  inicial  de  tonsilitis  poco  despues  del  nacimiento.  Este  fue  seguido 
por  una  infeccion  gastro  intestinal  con  agrandamiento  del  bazo. 

Los  sintomas  clinicos  principales  fueron  entorpecimiento,  estupor, 
paralises  nerviosa,  contracciones  faciales,  rigidez  de  las  extremidades  y 
ataques  convulsivos. 

En  la  autopsia  se  encontro  una  tuberculosis  miliar  muy  extendida  en 
todos  los  organos  del  cuerpo.  La  fuente  de  esta  infeccion  fue  una  cavidad 
en  el  vertice  del  pulmon.  En  este  lugar  se  encontro  una  cavidad  como 
de  dos  centimetres  de  diametro  con  una  area  de  degeneration  caseosa  que 
se  extendia  desde  esta  cavidad  al  asiento  del  pulmon  derecho.  Las  glandu- 
las  peri-bronquiales  se  encontraron  agrandadas  y  con  una  degeneracion 
caseosa.  Este  caso  parece  ser  uno  de  infeccion  intestinal  con  una  afeccion 
secundaria  del  pulmon  con  una  tuberculosis  miliar  primaria  y  meningitis 
tuberculosa  secondaria. 


Manifestations  cliniques  de  M€ningite  tuberculeuse. 

Tuberculose  miliare  avec  la  Meningite  tuberculeuse  chez  un  Enfant  de 
17  Semaines. — -(McCarthy  et  Fife.) 

Les  types  suivants  de  cas  atypiques  seront  consid^res : 

La  meningite  tuberculeuse  comme  manifestation  locale  de  le  bacteremia 
tuberculeuse. 

Des  paralysies  irr^guli^res,  passag^res  sp^cialement  des  muscles  des 
yeux,  excite  et  dilatation  des  pupilles  dues  k  une  hydroc^phalie  interne,  stu- 
peur  et  delirium  permettent  de  discerner  ce  type. 

La  tuberculose  des  mineurs  et  I'infection  septique.  L'embarras  du 
nerf  cranien  est  dans  ce  cas  trds  limits,  mais  le  pouls  peut  etre  plus  frequent. 

La  meningite  tuberculeuse,  localisde  celle-ci  doit  etre  discernde  par  le 
symptome  localise  dans  un  cas  de  tuberculose  pulmonaire. 

Des  types  en  cours  de  maladie  et  des  types  en  train  de  gudrir  montrent 


414  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS- 

au  point  cle  vue  pathologique  de  petits  tubercules  avec  des  cellules  a  forme  de 
fuseau,  des  cas  extremes  avec  hemorragie. 

Des  cas  associds  au  traumatisme;  ces  derniers  sont  de  valeur  medico- 
legale  considerable. 

Le  but  de  cette  communication  est  d'appeler  I'attention  sur  le  fait  qu'il 
faut  decouvrir  la  source  de  I'infection  et  que  le  diagnostic  du  laboratoire 
doit  etre  considerd  comme  de  valeur  secondaire. 

Ce  cas  est  celui  d'un  enfant  de  17  semaines  qui  fut  atteint  d'une  attaque 
initiale  d'amygdalite  (ou  angine)  peu  apres  sa  naissance,  suivie  d'infection 
gastro-intestinale  avec  elargissement  de  la  rate. 

Les  symptomes  cliniques  furent:  assoupissement,  stupeur,  paralysie 
passagere  du  troisieme  nerf,  contortions  faciales,  rigidity  des  extrdmites 
et  attaques  de  convulsions. 

L'autopsie  a  rdvele  une  tuberculose  miliaire  tr^s-etendue,  affectant  tous 
les  organes  du  corps.  La  source  de  I'infection,  selon  toute  probabilite, 
etait  une  vieille  lesion  au  sommet  du  poumon  droit;  a  ce  point,  il  y  avait 
une  cavite  de  2  cm.  cle  diametre  avec  une  surface  de  degenerescence  caseeuse 
s'etendant  de  cette  cavite  a  la  base  du  poumon  droit.  Les  glandes  peri- 
bronchiales  etaient  agrandies  et  casdeuses.  Les  glandes  mesenteriques 
etaient  egalement  agrandies  et  la  base  en  etat  de  degenerescence  caseeuse. 
Ce  cas  semble  etre  un  cas  d'infection  intestinale  avec  implication  secondaire 
du  poumon  par  une  tuberculose  miliaire  primaire  et  une  meningite  tuber- 
culeuse  secondaire. 


Die  klinischen  Erscheinungen  der  tuberkulbsen  Gehirnhaut-Entziindung. 

Miliartuberculose,  associirt  mit  tuberculoser  Meningitis  in  einem  17 
Wochen  alten  Sauglinge. — (McCarthy  und  Fife.) 

Folgende  atypische  Formen  sollen  Besprechung  finden: 

Meningitis  tuberculosa  als  Lokalmanifestation  einer  tuberkulosen 
Bakteramie. 

Unregelmassige  fliichtige  Lahmungen,  namentlich  der  Augenmuskeln, 
Erblindung  und  Dilatation  der  Pupillen  durch  Hydrocephalus  internus, 
Stupor  und  Delirium  sind  charakteristische  Anzeichen. 

Tuberkulose  und  septische  Infektion:  die  Cranialnerven  sind  hier 
wenig  in  Mitleidenschaft  gezogen;  der  Pulsschlag  ist  gewohnlich  rapid. 

Lokalisirte  tuberkulose  Meningitis:  gekennzeichnet  durch  Lokalsymp- 
tome  in  einem  Falle  von  Lungentuberkulose. 

Produktive  und  heilungsfahige  Typen,  die  pathologisch  keine  Tuberkel 
mit  spindelformigen  Zellen  aufweisen.     Foudroyante  Typen  mit  Blutungen. 


TUBERCULOUS   MENINGITIS. — MCCARTHY    AND   FIFE.  415 

Falle  infolge  von  Traumatismus,  bedeutenden  forensisch-medizinischen 
Werth  besitzend. 

Die  Arbeit  bezweckt,  darauf  hinzuweisen,  dass  vor  allem  die  Quelle  der 
Infektion  zu  eruiren  sei  und  die  Laboratorium-Diagnose  erst  in  zweiter 
Reihe  in  Betracht  komme, 

Kurz  nach  der  Geburt  war  bei  dem  17  Wochen  alten  Kinde  eine  Ton- 
sillitis aufgetreten.  In  der  Folge  hatte  sich  dann  eine  Gastrointestinal- 
Infection  mit  Milzschwellung  entwickelt. 

Die  markantesten  klinischen  Anzeichen  waren  Benommenheit,  Stupor, 
voriibergehende  Lahmung  des  dritten  Nerven.  Gesichts-Zuckungen,  Rigidi- 
tat  der  Extremitaten  und  Convulsionen. 

Die  Autopsie  ergab  eine  extensive  Miliartuberkulose,  die  sich  auf  sammt- 
liche  Organe  erstreckte.  Die  Infectionsquelle  war  anscheinend  eine  alte 
Lasion  im  rechten  Lungenspitz,  Hier  befand  sich  eine  Caverne  von  2  cm. 
Durchmesser,  von  der  sich  die  kasige  Degeneration  iiber  die  rechte  Lunge 
verbreitet  hatte.  Die  Peribronchial-Driisen  waren  geschwoUen  und  kasig 
verartet,  ebenso  die  IMesenterialdriisen.  Es  scheint  dies  ein  Fall  von  In- 
testinal-Infection zu  sein,  dem  sich  eine  primare  Miliartuberkulose  und 
secundare  Meningealtuberculose  angereiht  hatte. 


DISCUSSION. 

Dr.  Lawrence  Litchfield  (Pittsburg)  furnished  the  following  history: 

Patient,  R.  W.  S.  Born  January  27,  1907.  White.  First  and  only 
child.  Full  term;  natural  delivery,  not  prolonged,  no  instruments  used. 
Head  always  large,  but  well  formed.  Child  bright,  but  not  precocious. 
Veins  in  face  and  scalp  never  conspicuous.     Face  well  proportioned. 

In  November,  1907,  had  a  slight  illness  attributed  to  indigestion,  tem- 
perature going  up  to  104°;  vomiting  at  onset,  followed  by  drowsiness.  Phy- 
sical examination  negative.  Rapid  return  to  normal  health  and  strength. 
During  the  spring  of  1908  his  development  was  normal,  flesh  firm,  and  color 
good.     Was  considered  an  exceptionally  strong  and  healthy  child. 

In  May,  1908,  he  became  fretful,  peevish,  and  his  appetite  became  cap- 
ricious. About  the  22d  of  May  some  temperature  was  noticed,  and  he  began 
to  vomit  his  food.  He  had  sixteen  teeth,  and  the  other  four  seemed  to  be 
rapidly  developing.  Had  been  walking  for  several  months,  I  think.  Phy- 
sical examination  negative.     No  cough,  no  cold.     Ear-drums  both  normal. 

June  3d:  Condition  much  the  same;  patient  irritable,  cries  in  a  whining 
manner  frequently;  sleeps  well  at  night;  appetite  poor;  bowel  movements 
frequent,  mucus  in  stools;  temperature,  102.3°. 

June  8th:  Condition  remained  much  the  same  until  yesterday.  To-day 
temperature  100°;  pupils  widely  dilated,  eyes  turned  up  and  to  left;  reflexes 
increased;  crying  the  same;  bowel  movements  still  frequent  and  contain 
mucus. 

June  9th:  Had  several  slight  convulsions  during  the  night,  and  severe 


416  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

one  about  9  a.m.,  and  again  at  10  and  10.30.  Unconscious  for  a  while, 
but  brightened  up,  recognizing  parents.  Left  ear-drum  very  slightly  con- 
gested; drum  punctured,  with  the  escape  of  a  little  clear  serum. 

June  10th:  Convulsions  continued  at  more  or  less  frequent  intervals; 
between  them,  left  arm  rather  limp. 

June  11th:  Slight  convulsions,  twitching  of  right  hand.  Temperature 
normal  for  two  days;  pulse  88,  good  quality;  patient  taking  nourishment 
better. 

June  12th:  Temperature  normal  all  day  yesterday.  Pulse  88,  good 
quality;  slight  discharge  from  left  ear.  Eight  to  ten  convulsions  yesterday 
involving  arms,  right  leg,  left  side  of  face.  To-day  hemoglohin  65  per  cent.; 
leukocytes,  13,500.  Lumbar  puncture  is  done;  eight  to  ten  minims  of  clear 
fluid  obtained,  containing  a  few  red  blood-corpuscles,  few  very  large  and  few 
very  small  mononuclear  leukocytes  or  endothelial  cells,  no  organisms. 

June  13th:  Area  of  clearly  defined  marked  dullness  discovered  over  left 
parietal  region  just  above  the  ear.  Operation  decided  upon  and  done. 
Bone  flap  made,  meninges  exposed,  slightly  congested  and  bulging.  Left 
ventricle  punctured,  with  the  escape  of  a  number  of  ounces  of  clear,  straw- 
colored  fluid,  which  later  on  was  found  to  contain  a  few  red  blood-corpuscles, 
very  few  leukocytes,  and  no  organisms.  Child  survived  thirty-six  hours; 
convulsions,  which  had  been  half  hourly  just  before  operation,  did  not  re- 
turn, but  there  was  some  nervous  twitching  during  the  night,  and  occasional 
rigidity  in  early  morning,  and  again  the  following  morning  just  before  death. 

Post-mortem:  With  exception  of  dilated  ventricles,  and  flattening  of  the 
convolutions,  no  gross  lesions  were  discovered. 

Pathological  Report  by  Dr.  E.  W.  Willetts:  Several  pieces  of  brain  tissue 
preserved  in  weak  formaldehyd  solution.  Gross  examination:  ventricu- 
lar surface  showed  a  number  of  small  nodules,  size  of  a  pinhead,  on  the  sur- 
face of  the  lining  of  the  ventricle.  Sections  through  these  small  masses, 
on  staining,  consisted  of  large  cells  with  reticulated  nuclei  staining  poorly. 
Scattered  around  these  were  a  few  small  round  cells  with  fibrous  stroma 
supporting  them.  There  were  no  giant-cells.  Beneath  the  ependyma  were 
a  number  of  smaller  collections  of  similar  cells,  apparently  miliary  tubercles. 
Brain  cells  stained  poorly.  There  is  no  suggestion  of  inflammation.  The 
convexity  of  the  brain  and  the  pia  showed  no  evidence  of  inflammation. 
Stain  negative  for  tubercle  bacilli.  Delafield  and  Prudden  show  similar 
picture  of  acute  internal  hydrocephalus.     There  was  no  caseation. 

At  the  time  of  the  patient's  illness  there  was  not  known  to  be  any  case  of 
tuberculosis  in  the  family.  When  the  baby  was  about  eight  months  old, 
his  father  had  an  acute  illness  with  liigh  fever,  headache,  etc.,  for  several 
days.  Two  months  later  he  had  a  similar  attack  and  was  confined  to  his 
bed  about  two  weeks.  The  lungs  were  carefully  examined,  with  negative 
results.  His  lungs  were  again  examined  in  February,  1908,  and  pronounced 
normal.  He  was  noted  at  this  time  to  have  a  rather  rapid  pulse,  and  on 
several  occasions  one  or  two  degrees  of  temperature.  In  August,  1908,  he 
came  to  my  office  again  complaining  of  cold  in  the  head  with  cough,  hoarse- 
ness, and  expectoration.  No  night-sweats,  or  loss  of  weight.  Physical 
examination  showed  signs  of  slight  consolidation  at  the  left  apex;  and  the 
sputum  was  streaked  with  blood  and  contained  many  tubercle  bacilli. 
Temperature  taken  carefully  for  several  days  showed  no  evening  rise. 


THE  LOCALIZATION  OF  TUBERCULOSIS  IN  CHILDREN. 

By  Woods  Hutchinson,  A.M.,  M.D., 

New  York. 


While  our  knowledge  of  tliis  subject  is  fairly  extensive,  our  ignorance  is 
equally  so,  and  far  more  profound.  We  are  more  deeply  impressed  with 
what  we  do  not  know  about  it  than  we  were  twenty  years  ago.  The  princi- 
pal purpose  of  this  commimication  is  to  call  attention  to  the  gaps  in  our 
knowledge,  and  to  suggest  lines  along  which  clinicians,  pathologists,  and 
sanatorium  founders  may  cooperate  to  fill  them. 

Briefly,  the  three  great  needs  for  the  further  gi'owth  of  knowledge  in 
regard  to  tuberculosis  in  children  seem  to  me  to  be: 

First,  to  "wipe  completely  off  our  diagnostic  slate  the  old  clinical  picture 
of  pulmonary  tuberculosis,  based  upon  a  gi'oup  of  symptoms  presented  in 
the  adult,  and  the  careful  redrawing  of  an  almost  entirely  new  picture  of 
the  pulmonary  form  of  disease  as  it  presents  itself  in  childhood. 

Second,  a  wide  and  systematic  study,  with  the  most  thorough  modern 
methods  of  diagnosis,  not  merely  of  cliildren  who  to  the  dull  eye  of  their 
immediate  family  are  obviously  sufficiently  ill  to  be  brought  to  a  dispensary 
or  hospital,  or  even  to  a  private  physician,  but  of  all  children  who  are  known 
to  have  been  exposed  to  infection  in  the  house  or  family,  and  of  large  bodies 
of  children  in  schools  and  institutions,  who  are  not  especially  under  sus- 
picion of  infection. 

Third,  the  establishment  of  sanatoriums  or  camps  for  the  reception  and 
treatment  of  children  suffering  from  pulmonary  tuberculosis.  At  present, 
these  are  practically  non-existent.  Neither  our  treatment  nor  our  knowl- 
edge of  the  disease  can  hope  to  become  effective  and  adequate  unless  we 
have  an  opportunity  of  studying  large  numbers  of  cases  together,  under 
conditions  suitable  for  adequate  control  and  observation.  The  value  of 
the  sanatorium  as  a  means  of  increasing  our  knowledge  of  tuberculosis  has 
been  even  greater  than  its  curative  influence. 

The  amount  of  work  done  and  the  masses  of  data  accumulated  upon  this 

subject  are  enormous.     But  it  would  probably  be  fair  to  say  that  the  chief 

net  result  of  their  accumulation  so  far,— and  probably  the  most  useful,— has 

been  to  make  us  doubt  the  correctness  of  our  previous  views.     And  the 

VOL.  11 — 14  417 


418  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

process  is  still  continuing.  Half  a  century  ago  we  felt^fairly  confident  that, 
while  the  pulmonary  form  of  tuberculosis  was  both  the  commonest  and  the 
most  frequent  cause  of  death  in  adults,  this  was  not  the  case  in  children; 
but  that,  on  the  contrary,  certain  other  organs^and  gi'oups  of  tissues  were 
more  frequently  the  site  of  the  disease — notably  the  lymph-glands,  the  bones 
and  joints,  and  the  meninges.  Tuberculosis  was,  in  fact,  regarded  as  a 
generalized  disease  in  children,  and  as  a  localized  one  in  adults.  Most  of 
the  older  text-books  flatly  state  that  pulmonary  tuberculosis  is  rare  in 
children  under  the  age  of  ten,  or  even  as  late  as  fifteen  j^ears.  And  even  as 
recently  as  the  last  United  States  Census,  and  the  mortality  reports  of  the 
New  York  City  Board  of  Health,  we  find  the  mortality  from  the  pulmonary 
form  of  tuberculosis  in  children  far  outranked  by  the  osseous,  the  meningeal, 
and  even  the  intestinal.  Indeed,  so  far  as  statistics  based  upon  mortality 
records  are  concerned,  all  over  the  world  to-day  pulmonary  tuberculosis 
would  appear  to  be  one  of  the  least  frequent  forms  of  fatal  tuberculosis  in 
children.  So  universally  is  this  apparent  condition  accepted  as  a  fact  that 
it  gives  rise  to  some  most  extraordinary  misunderstandings.  For  instance, 
when  so  distinguished  and  eminent  a  statistician  as  Mr.  Karl  Pearson,  in 
his  recent  admirable  work  upon  the  inheritance  of  pulmonary  tuberculosis, 
explains  the  discrepancy  between  two  groups  of  percentages  of  tuberculosis 
by  the  statement  that  one  of  them  contained  a  large  number  of  children 
under  the  age  of  fifteen,  "in  which  period  consumption  is  extremely  rare." 
With  the  discovery  of  the  bacillus,  and  the  succeeding  demonstration  of 
the  tuberculous  nature  of  the  old  "struma"  and  "scrofulous"  gi"oup  of 
lesions  of  the  skin  and  bones,  the  special  tendency  of  tuberculosis  to  localize 
in  these  structures  in  children  seemed  strikingly  corroborated.  But  in  the 
meantime  other  data  were  accumulating,  which  were  destined  to  seriously 
undermine  it.  This  was  the  accumulation  of  thorough  and  systematic 
post-mortem  examinations  of  the  bodies  of  children  dead  of  all  sorts  of 
diseases.  So  long  as  these  examinations  merely  confined  themselves  to 
ascertaining  the  probable  cause  of  death,  comparatively  little  progress  was 
made.  But  when  the  practice  was  once  established  of  thoroughly  and  sys- 
tematically examining  every  organ  and  important  tissue  of  the  body  with 
reference  to  the  possible  presence  of  tuberculosis,  then  a  very  different  state  of 
affairs  began  to  reveal  itself.  Instead  of  the  lung  being  the  least  frequently 
affected  organ,  it  was  found  to  be  the  most  so.  What  made  these  results 
the  more  interesting  and  the  more  unexpected  was  that  many  of  them  were 
carried  out  in  the  attempt,  which  is  still  persisting,  to  discover  through  the 
localization  of  these  lesions  the  port  of  entry  and  probable  source  of  the 
infection.  Those  observers,  who  are  inclined  to  believe  that  the  infection 
in  tuberculosis  came  chiefly  through  ingestion,  were  specially  interested  in 
involvements  of  the  intestines  and  of  the  mesenteric  glands.     But  however 


THE  LOCALIZATION  OF  TUBERCULOSIS  IN  CHILDREN. — HUTCHINSON.      419 

few  or  numerous  these  might  be  found  to  be,  they  were  always  well  below 
the  lungs  in  frequency  of  involvement. 

In  fact,  the  more  thorough  and  systematic  these  examinations  were  made, 
and  the  more  frequently  inoculation  tests  were  included,  the  more  nearly 
universal  became  the  degree  of  pulmonary  involvement,  until  some  of  the 
later  data,  like  Kossel's,  record  as  high  as  93  per  cent,  of  pulmonary  lesions. 
Adams,  of  the  Washington  Hospital,  gives  90  per  cent,  of  lung  and  bronchial 
involvement,  while  in  Holt's  119  cases  under  three  years  the  lungs  were 
affected  in  99  per  cent,  and  the  bronchial  lymph-nodes  in  96  per  cent. 

Almost  equally  striking  is  the  change  that  has  come  over  our  reports  of 
the  percentage  of  tuberculous  lesions  in  the  children  admitted  to  our  clinics 
and  pediatric  hospitals.  As  recently  as  five  years  ago  these  percentages 
ranged  from  half  of  1  per  cent,  to  2  per  cent.,  3  per  cent,  or  occasionally  as 
high  as  6  per  cent.  Now  the  proportion  of  cases  of  tuberculosis  admitted 
to  children's  hospitals  has  reached  25  per  cent.,  30  per  cent.,  and  35  per  cent. 
Indeed,  Holt's  latest  reports  give  41  per  cent. — and  the  end  is  not  yet. 
These  increasing  percentages — due  entirely  to  a  more  adequate  knowledge 
of  the  disease,  more  thorough  examinations,  and  consequently  gi'eater 
accuracy  of  diagnosis — furnish  at  least  a  part  of  the  basis  for  the  claim  fre- 
quently advanced  that  tuberculosis  is  increasing  in  frequency  in  young  chil- 
dren, while  diminishing  at  every  other  age. 

In  fine,  all  the  data  at  our  disposal  point  clearly  to  the  fact  that  tubercu- 
losis of  all  varieties  is  vastly  more  common  in  young  children  (at  all  events, 
young  children  in  the  hospital  classes)  than  was  previously  believed.  And 
while  they  do  not  as  yet  appear  to  have  thrown  much  light  upon  the  precise 
source  of  infection,  whether  human  or  bovine,  inhalation  or  ingestion,  yet 
they  do  justify  us  in  regarding  the  question  of  infection  as  in  large  measure  a 
problem  of  infancy  and  early  childhood.  If  we  can  control  the  spread  and 
development  of  tuberculosis  during  the  first  five  years  of  life,  we  can  control 
its  entire  progress  in  the  community.  As  certain  of  our  great  religious 
schools  used  to  say:  "Give  us  the  teaching  of  a  child  until  ten  years  of  age, 
and  we  care  not  who  attempts  to  mold  him  after  that."  In  eight  cases  out 
of  ten  we  are  almost  prepared  to  say  that,  given  an  ideal  environment  up 
to  the  tenth  year,  and  we  can  go  far  to  guarantee  the  child  against  the  devel- 
opment of  tuberculosis  in  later  life. 

An  exceedingly  interesting  and  valuable  contribution  to  the  study  of 
this  problem  has  recently  been  made  by  the  various  dispensaries  for  the  care 
of  tuberculosis  in  several  of  our  larger  cities,  by  extending  the  study  of  the 
tuberculous  individual  so  as  to  include  the  members  of  his  or  her  family. 
Wherever  it  is  feasible,  the  nurses  attached  to  such  a  dispensary,  when  visit- 
ing the  patients  in  their  homes,  make  inquiries  as  to  the  existence  and  num- 
ber of  children  in  the  family.     If  any  are  present,  they  are  brought  into  the 


420  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

clinic,  regardless  of  their  apparent  condition  of  health,  to  be  carefully  and 
thoroughly  examined  for  the  existence  of  tuberculosis  in  any  form.  The 
results  are  little  short  of  appalling,  showing  that  from  20  per  cent,  to  as  high 
as  50  per  cent,  of  all  the  children  of  tuberculous  parents,  thus  brought  in 
for  examination,  are  suffering  from  the  disease  in  some  form,  the  general 
average  being  in  the  neighborhood  of  30  per  cent.  The  better  the  oppor- 
tunities and  the  more  careful  and  exhaustive  the  examination  and  testing, 
the  higher  the  percentage  discovered. 

I  have  also  visited  most  of  the  hospitals  and  institutions  in  and  near 
New  York  which  are  devoted  to  the  care  of  tuberculous  children.  These, 
unfortunately,  though  not  unnaturally,  in  view  of  our  lateness  in  the  recog- 
nition of  the  occurrence  of  pulmonary  tuberculosis  in  children,  are  chiefly 
limited  to  cases  of  bone,  joint,  and  glandular  tuberculosis.  Indeed,  only  one, 
in  all  this  array,  will  admit  children  suffering  from  pulmonary  lesions,  on 
account  of  the  danger  of  infection. 

The  experience  of  the  physicians  in  the  orthopedic  hospitals  and  wards 
is  almost  unanimous,  and  in  accord  with  the  views  generally  held  by  the  pro- 
fession and  the  text-books — that  children  suffering  from  joint  and  bone 
tuberculosis  comparatively  seldom  show  definite  or  progressive  lesions  in  the 
lung.  If  such  lesions  be  present,  they  are  in  a  comparatively  dormant  or 
recessive  stage ;  and  in  the  vast  majority  of  instances  do  not  progress,  but 
clear  up  and  disappear  under  the  treatment — and  pari  passu — with  the  im- 
provement of  the  bone  and  joint. 

On  the  other  hand,  the  results  of  Dr.  Miller  and  Dr.  Woodruff's  exceed- 
ingly careful  and  painstaking  study  of  150  children  of  tuberculous  parents 
show  first,  that  the  disease  was  present  in  51  per  cent.,  but  that  in  only  1  per 
cent,  did  it  occur  in  the  bones  or  the  joints,  while  71  per  cent,  of  those  in- 
fected presented  definite  pulmonary  signs,  and  20  per  cent,  more  gave  a 
history  of  a  cough. 

Secondly,  instead  of  the  glandular  form  of  the  disease  being  an  earlier 
stage,  the  precedent  of  a  pulmonary  inflammation,  though  enlarged  glands 
were  present  in  79  out  of  the  150  cases,  only  a  little  over  half  of  these  could 
be  shown  to  be  tuberculous,  and  the  vast  majority  of  these  had  pulmonary 
involvement  as  well.  It  would  almost  appear  as  if  these  unexpected  find- 
ings supported  the  suggestion  that  the  pulmonary  lesion  was  primary  in 
both  bony  and  articular  tuberculosis  and  in  glandular  tuberculosis. 

Thirdly,  of  the  other  group  of  glandular  bodies  supposed  to  be  closely 
associated  with  tuberculosis,  as  ports  of  entry,  if  in  no  other  way,  hyper- 
trophied  tonsils  and  adenoids,  the  connection  is  even  less  positive.  Sixty- 
five  out  of  the  150  cases  had  hypertrophied  tonsils  and  adenoid  growths. 
Out  of  this  number,  only  31,  or  47  per  cent.,  were  considered  tuberculous,  as 
compared  with  51  per  cent,  of  the  entire  number,  which  gave  positive 


THE  LOCALIZATION  OF  TUBERCULOSIS  IN  CHILDREN. — HUTCHINSON.      421 

reactions.  In  other  words,  instead  of  a  larger  percentage  of  those  having 
adenoids  giving  evidence  of  tuberculosis,  a  smaller  percentage  than  the 
average  did  so. 

Finally,  careful  physical  examination  of  the  lungs  and  chest  have 
gone  far  to  establish  a  new  clinical  picture  for  pulmonary  tuberculosis 
in  children,  with  the  most  frequent  and  significant  local  lesions  not  in  the 
apices,  but  in  the  neighborhood  of  the  nipples,  below  and  slightly  external 
to  them,  and  more  frequently  in  the  left  one,  instead  of  in  the  right,  as  in  the 
adult. 

Further,  the  valuable  data  collected  by  the  physicians  to  the  now  famous 
Sea  Breeze  Home  for  Crippled  Cliildren  show  that  repeatedly  the  child  with 
Pott's  hip-joint  disease  comes  from  an  infected  home,  and  is  often  the  sole 
survivor  of  a  family  of  four  or  five  children  dead  of  other  forms  of  tuber- 
culosis. Dr.  Charlton  Wallace's  painstaking  study  of  443  children  with 
tuberculous  bone  lesions,  received  at  the  New  York  Hospital  for  the  Ruptured 
and  Crippled,  showed  that  196  came  from  houses  recorded  as  previously  in- 
fected, and  130  from  tuberculous  families,  a  total  of  73  per  cent,  giving  clear 
history  of  exposure  to  infection. 

The  data  so  far  collected  appear  to  point  toward  the  following  conclusions 
as  probable :  First,  that  the  frec^uency  of  pulmonary  tuberculosis  in  children 
is  much  greater  than  was  formerly  supposed.  Second,  that  the  lung  is  the 
most  frequent  site  of  tubercular  involvement  in  children,  as  in  adults. 
Third,  that  whatever  the  port  of  entry,  the  lung  suffers  most  severely  and 
frequently.  Fourth,  that  instead  of  tuberculosis  having  a  special  preference 
for  the  bones,  joints,  and  glands  in  childhood,  the  tuberculous  process  in 
these  regions  and  tissues  would  appear  to  be  secondary  to  the  involvements 
of  the  lung,  and  to  represent  a  residual  stage  of  a  generalized  infection. 
Fifth,  that  it  would  appear  probable  that  even  the  glandular  forms  of  tuber- 
culosis did  not  represent  an  earlier  or  milder  form  of  the  infection,  but  are 
secondary  to  a  pulmonary  involvement.  Sixth,  that  the  moderate  but  ap- 
preciable degi'ee  of  immunity  against  pulmonary  tuberculosis  possessed  by 
children  who  have  manifested  osseous,  articular,  or  glandular  forms  of  the 
disease  is  possibly  to  be  interpreted  on  the  theory  that  they  have  already 
survived  a  considerable  degree  of  pulmonary  involvement.  Seventh,  that 
such  immunity  as  may  be  acquired  by  civilized  races  is  probably  like  the 
immunity  of  the  negro  races  to  malaria — the  result  of  the  survival  of  attacks 
of  the  pulmonary  form  of  the  disease  in  childhood.  Lastly,  that  the  field  in 
which  the  decisive  battle  of  our  future  campaign  against  tuberculosis  must 
be  fought  is  the  home;  our  chief  enemy,  infection  in  early  childhood; 
our  heaviest  gun,  and  our  most  crying  need,  camps,  "  preventoria,"  for  the 
reception  and  cure  of  infected  children  before  they  have  become  unmis- 
takably tuberculous. 


422  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

La  Localisation  primaire  de  la  Tuberculose  chez  les  Enfants. — 

(Hutchinson.) 

Les  chiffres  obtenus  jusqu'ici  semblent  faire  prevoir  les  conclusions 
suivantes  comme  probables:  1.  Que  la  tuberculose  pulmonaire  chez  les 
enfants  est  beaucoup  plus  frequente  qu'on  le  supposait  autrefois.  2.  Que 
le  poumon  chez  les  enfants,  comme  chez  les  adultes,  est  le  siege  le  plus 
frequent  des  troubles  tuberculeux.  3.  Quel  que  soit  le  point  d'entree,  le 
poumon  est  le  plus  s^verement  et  le  plus  frequemment  affects.  4.  Que  la 
tuberculose  n'a  pas  une  preference  speciale  pour  les  os,  les  articulations  et 
les  glandes  chez  les  enfants,  mais  que  le  progres  de  la  tuberculose  dans  ces 
regions  et  ces  tissus  semblerait  etre  secondaire  aux  troubles  existant  dans 
les  poumons  et  representer  un  ^tat  residuel  d'une  infection  generale.  5. 
Qu'il  semblerait  probable  que  meme  les  formes  glandulaires  de  la  tuberculose 
ne  representent  pas  une  forme  plus  precoce  et  plus  benigne  de  I'infection, 
mais  sont  secondaires  a  des  troubles  pulmonaires.  6.  Que  le  degre  d'immu- 
nite,  modere,  quoique  appreciable,  contre  la  tuberculose  pulmonaire,  dont 
jouissent  des  enfants  qui  ont  exhib6  des  formes  osseuses,  articulaires  ou 
glandulaires  de  la  maladie,  pent  etre  exphquee  par  la  theorie  que  ces  enfants 
ont  deja  survecu  un  degre  considerable  de  troubles  pulmonaires.  7.  Que 
cette  immunite,  comme  celles  qui  peuvent  etre  acquises  par  les  races  civilisees, 
est  probablement  comme  1 'immunity  des  races  negres  pour  la  malaria — elle 
r^sulte  d'avoir  survecu  aux  attaques  des  formes  pulmonaires  de  la  maladie 
dans  I'enfance. 

Enfin,  que  le  terrain  ou  aura  lieu  la  bataille  decisive  de  notre  future 
campagne  contre  la  tuberculose,  est  la  maison;  notre  ennemi  principal, 
I'infection  dans  les  premieres  annees  de  I'enfance;  nos  plus  forts  canons  de 
protection  et  notre  besoin  le  plus  pressant,  des  camps,  des  "  preventoria " 
pour  recevoir  et  traiter  les  enfants  infectes  ou  exposes,  avant  qu'ils  ne 
soient  devenus  surement  et  completement  tuberculeux. 


THE  DISTRIBUTION  OF   TUBERCULOUS   LESIONS   IN 

INFANTS  AND  YOUNG  CHILDREN:  A  STUDY  BASED 

UPON  POST-MORTEM  EXAMINATIONS. 

By  Martha  Wollstein,  M.D., 

Pathologist  to  the  Babiea'  Hospital,  New  York  City 


In  view  of  the  interest  and  importance  of  the  question  concerning  the 
manner  of  infection  and  the  locaUzation  of  tuberculous  lesions  in  the  human 
subject,  it  seemed  that  the  analysis  of  the  autopsy  material  at  the  Babies' 
Hospital,  of  the  city  of  New  York,  would  prove  of  value  in  showing  the  facts 
in  a  number  of  city-bred  infants  and  young  children,  the  gTeat  majority 
from  the  most  crowded  and  unhygienic  tenement  districts,  badly  fed  and 
badly  cared  for  before  entering  the  hospital  in  all  stages  of  tuberculosis. 

From  October,  1889,  to  July,  1908,  1131  autopsies  were  performed,  of 
wliich  185,  or  16.4  per  cent.,  showed  tuberculous  lesions  in  one  or  more  organs. 
The  hospital  admits  children  under  three  years  only,  and  the  records  show 
that  60  per  cent,  of  all  admissions  are  infants  under  one  year  of  age,  and  that 
the  death-rate  is  exactly  three  times  as  high  among  these  young  babies  as  it 
is  among  the  children  from  one  to  three  years  old.  Of  all  the  autopsies  per- 
formed, 77  per  cent,  were  on  infants  under  one  year,  and  26  per  cent,  under 
three  months  of  age,  while  only  5  per  cent,  were  on  cliildren  older  than  two 
years,  including  four  who  were  four  years  old. 

From  the  185  cases  of  tuberculosis,  we  learn  that  11  per  cent,  of  all  in- 
fants under  one  year  of  age  coming  to  autopsy  showed  tuberculous  lesions, 
wliile  35  per  cent,  of  those  between  one  and  two  years,  and  27  per  cent,  of 
those  over  two,  were  so  affected.  Of  infants  under  three  months  of  age,  but 
If  per  cent,  had  tuberculosis.  These  figures  are  rather  higher  than  those 
reported  by  Frobelius  (2.2  per  cent.),  Heubner  (3.2  per  cent.),  Kossel  (6  per 
cent.),  Orth  (3.4  per  cent.),  and  Sehlbach  (7.8  per  cent.),  in  babies  under  one 
year  of  age,  and  approach  more  nearly  those  of  iMamburger  (15.4  per  cent.) 
and  of  Trepinski  (15  per  cent.),  whose  second-year  statistics  (34.5  per  cent.) 
also  coincide  closely  with  our  own,  Hamberger's  40  per  cent,  of  second-year 
children  being  somewhat  higher.  Contrasting  the  percentage  of  cases  af- 
flicted with  tuberculosis  in  the  four  quarters  of  the  first  year  of  life,  we  find: 

423 


424 


SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 


First  Year. 

Second  Year. 

Ist  Quarter. 

2d  Quarter. 

3d  Quarter. 

4th  Quarter. 

1st  Half. 

2d  Half. 

lf% 

11% 

16% 

23% 

33% 

44% 

Hamburger's  figures  for  the  same  period  are  as  follows: 

1st  Quarter. 

2d  Quarter. 

3d  and  4th  Quarters. 

Second  Year. 

4% 

18% 

23% 

40% 

Both  tables  show  a  progressive  increase  in  the  number  of  tuberculosis 
autopsies  throughout  the  first  and  second  years  of  life.  Seventy-eight  girls 
and  107  boys  were  affected. 

The  higher  percentage  of  tuberculosis  in  young  infants  in  our  cases  may 
be  partly  dependent  upon  the  fact  that  many  nationalities  are  comprised 
among  them,  living  under  climatic  and  other  conditions  which  differ  widely 
from  those  to  which  they  have  been  accustomed  in  their  native  land,  and  that 
overcrowding  and  lack  of  cleanliness  not  only  predispose  the  infants  to  in- 
fection, but  make  the  disease  rapidly  fatal. 

In  analyzing  this  series  of  cases,  it  seemed  most  rational  to  group  them 
according  to  the  relative  age  and  distribution  of  the  tuberculous  lesions, 
with  a  view  to  deducing  from  such  a  classification  such  facts  as  became  per- 
tinent from  its  study.  It  is  perfectly  true  that  the  localization  of  the  oldest 
lesion  is  not  always  synonymous  v/ith  the  point  of  entrance  of  the  tubercle 
bacillus,  and  that  the  greater  number  of  cases  of  extensive  pulmonary  as 
compared  with  intestinal  tuberculosis  by  no  means  proves  that  all  such  cases 
result  from  aspiration  rather  than  from  ingestion  of  the  bacilli.  It  has  been 
proved  by  Orth,  Ravenel,  Herman,  and  others,  that  the  tubercle  bacillus 
may  pass  through  the  normal  intestinal  wall  without  any  lesion  resulting  at 
that  point,  though  it  may  produce  tuberculosis  in  the  mesenteric  lymph- 
nodes  or  become  localized  there  for  a  shorter  or  longer  period  of  latency, 
causing  the  lymphoid  stage  of  tuberculosis  described  by  Bartel  and  Spieler, 
which  is  a  pre-tuberculous  stage  of  simple,  non-characteristic  hyperplasia, 
the  tuberculous  nature  of  which  can  only  be  demonstrated  by  means  of 
animal  inoculation  with  the  suspected  lymph-nodes.  The  studies  of  Bartel 
and  Newmann  showed  that  in  the  cervical  and  mesenteric  nodes  the  lymph- 
oid stage  tends  to  be  more  marked  than  in  the  bronchial  nodes,  which  present 
a  greater  tendency  to  cheesy  degeneration  than  do  the  mesenteries.  This 
latter  point  is  fully  borne  out  by  the  observation  of  our  cases.  It  is  never- 
theless difficult  to  understand  why  a  primary  pulmonary  (inhalation)  tuber- 


DISTRIBUTION  OF  LESIONS  IN  CHILDREN. — WOLLSTEIN.  425 

culosis  should  not,  by  the  swallowing  of  its  sputum,  cause  similar  hyperplas- 
tic changes  in  the  mesenteric  lymph-nodes,  these  being,  in  such  a  case,  of 
later,  and  not  of  earlier,  date  than  the  pulmonary  lesion.  Animal  experi- 
ments with  such  mesenteries,  if  positive,  would  hardly  elucidate  this  point, 
as  to  whether  the  localization  of  the  tubercle  bacilli  had  taken  place  before 
or  after  infection  of  the  broncliial  nodes  and  lungs.  That  the  intestines  and 
mesenteries  are  infected  secondarily  by  sputum  swallowing  in  patients  with 
pulmonary  tuberculosis  is  certain.  Why,  then,  should  it  not  be  possible 
to  obtain  such  a  case  at  autopsy,  with  the  mesenteries  so  slightly  changed  as 
to  simulate  the  lymphoid  stage  of  latency,  paradoxical  as  such  a  proposi- 
tion appears? 

According  to  the  lesions  found  in  my  cases,  they  may  be  grouped  as 
follows : 

Group  I. 

1.  Those  showing  pulmonary  lesions  only. 

2.  Those  showing  bronchial  lymph-node  lesions  only. 

3.  Those  showing  pulmonary  and  bronchial  node  lesions  alone. 

4.  Those  showing  pulmonary  and  bronchial  node  changes  as  the  most 
advanced  lesion  of  a  generalized  tuberculosis. 

Group  II. 

1.  Those  showing  intestinal  and  mesenteric  lymph-gland  lesions  only. 

2.  Those  showing  intestinal  and  mesenteric  changes  as  the  most  advanced 
lesion  of  a  partially  generalized  tuberculosis. 

3.  Those  showing  intestinal  and  mesenteric  lymph-gland  lesions  as  the 
most  advanced  in  a  completely  generalized  tuberculosis. 

No  case  of  congenital  tuberculosis  occurred  in  this  series.  The  youngest 
(two  cases)  were  seven  weeks  old.  In  one  the  lungs  and  bronchial  lymph- 
nodes  were  affected,  while  a  few  early  splenic  tubercles  gave  e^ddence  that 
hematogenous  generaUzation  had  begun.  The  other  presented  a  very 
generalized  tuberculosis,  the  bronchial  lymph-nodes  showing  a  more  ex- 
tensive cheesy  degeneration  than  the  mesenteric  nodes,  and  the  pulmonary 
lesion  being  more  advanced  than  any  other.  This  child's  mother  had  died 
of  "consumption"  during  the  second  week  of  the  infant's  life. 

Group  I. 
1.  Pulmonary  Lesions  Only. — There  were  four  such  instances,  the 
tuberculous  lesion  in  each  case  being  limited  to  one  lung  only,  and  consisting 
of  miliary  tubercles  in  two,  of  an  area  of  cheesy  pneumonia  in  another,  and 
of  several  small,  cheesy,  peri-bronchitic  nodules  in  the  fourth.  These  cases 
were  undoubtedly  of  inspiratory  origin.    The  bronchial  lymph-nodes  were 


426  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

swollen,  but  without  macroscopical  or  microscopical  evidence  of  tuberculo- 
sis.   Animal  inoculations  were  not  made. 

2.  Bronchial  Lymph-nodes  only  Involved. — In  one  case,  eight 
months  old,  several  nodes  at  the  root  of  the  right  lung  showed  tubercles 
with  cheesy  degeneration.  No  other  sign  of  tuberculosis  was  found  in  any 
organ,  and  the  case  was  grouped  as  one  due  to  inhalation,  since  the  lung, 
like  the  intestine,  may  allow  the  tubercle  bacillus  to  pass  through  without 
localizing  there. 

3.  Lungs  and  Bronchial  Nodes  Involved  Alone. — Thirteen  cases  of 
this  kind  were  noted,  in  which  the  tuberculous  process  was  limited  to  the 
lungs  and  bronchial  nodes,  all  other  organs  being  free.  It  has  been  our 
custom  to  group  these  also  as  inhalation  tuberculosis. 

Both  Weichselbaum  and  Weleminsky  look  upon  all  cases  involving  the 
bronchial  nodes  together  with  the  lungs  as  of  digestive  origin,  since  the  pri- 
mary lesion  in  the  mesenteric  or  cervical  nodes  may  be  in  the  lymphoid 
stage,  demonstrable  by  animal  inoculation  only,  or  else  even  this  may  have 
entirely  disappeared,  and  the  primary  lesion  cured  instead  of  latent.  This 
seems  both  far-fetched  and  unnecessary,  and,  in  the  light  of  Gaffky's  studies, 
untenable. 

On  the  other  hand,  Flugge's  experiments  show  that  tubercle  bacilli 
reach  the  hmgs  very  slowly  by  way  of  the  intestinal  tract,  and  that  relatively 
very  large  doses  are  required  to  cause  infection  by  way  of  the  intestine, 
while  exceedingly  small  numbers  will  cause  pulmonary  tuberculosis  when 
inhaled  in  the  moist  state,  as  proved  by  Findel. 

Both  Most  and  Beitzke,  having  shown  that  anatomically  the  tracheo- 
broncliial  lymph-nodes  are  not  connected  with  the  cervical  glands  on  the 
one  hand,  nor  with  the  abdominal  on  the  other,  secondary  infection  of  the 
bronchial  nodes  is  possible  only  by  way  of  the  blood-stream,  after  the  ab- 
dominal lymphatics  have  emptied  their  tubercle  bacilli  into  the  thoracic 
duct,  or  when  a  blood-vessel,  in  the  process  of  degeneration  of  the  nodes, 
has  been  entered  directly.  Oettinger  has  shown  very  recently,  by  means 
of  feeding  experiments,  that  tubercles  do  not  appear  in  the  lungs  before  they 
are  formed  in  the  other  organs.  When  the  digestive  tract  is  the  entrance 
point  for  the  bacilli,  and  when  tubercles  appear  in  the  lungs  and  not  in  the 
liver  and  spleen,  the  bacilli  did  not  enter  such  lungs  through  the  blood- 
stream. The  views  of  Flugge  and  Findel  are  confu^med  by  recent  studies  of 
Osterman,  Heymann,  Reichenbach,  and  Oettinger,  whose  animal  experi- 
ments all  tend  to  show  the  greater  frequency,  rapidity,  and  ease  of  the 
respiratory  over  the  digestive  method  of  tuberculous  infection,  a  view  which 
Kuss,  Medin,  and  Spronck  also  hold,  in  accordance  with  their  clinical  and 
autopsy  findings,  and  which  receives  further  confirmation  by  the  results  of 
Gaffky's  study  of  the  bronchial  and  mesenteric  lymph-nodes  from  a  series 


DISTRIBUTION  OF  LESIONS  IN  CHILDREN. — WOLLSTEIN.  427 

of  300  autopsies  in  children,  of  whom  272  were  under  five  years  of  age. 
The  glands  were  examined  for  tubercle  bacilli  by  the  inoculation  method, 
and  the  isolated  bacilli  tested  as  to  whether  they  were  of  the  human  or  bo- 
vine type.  The  result  showed  conclusively  that  the  human  t}^e  of  tubercle 
bacillus  was  almost  invariably  present ;  only  in  2  of  59  cases  was  the  bovine 
type  apparently  found,  and  even  then  the  bronchial  and  not  the  mesenteric 
glands  contained  them.  A  most  interesting  part  of  this  work  shows  that 
while  36  cases  were  macroscopically  tuberculous  at  autopsy,  90  others  were 
found  to  contain  tubercle  bacilli  in  the  lymph-glands  on  animal  inoculation. 
The  bronchial  nodes  were  found  infectious  for  tuberculosis  tvnce  as  often  as 
the  mesenteries  in  the  latent  cases,  and  as  often  in  the  developed  cases,  thus 
proving  that  even  in  cliildhood  the  respiratory  tract  is  more  frequently  the 
entrance  point  for  the  tubercle  bacillus  than  is  the  digestive  tract,  and  that 
it  is  the  human  and  not  the  bovine  tyi^e  of  tubercle  bacillus  which  causes 
the  greatest  danger  of  infection  in  human  beings. 

4.  Cases  Showing  Pulmonary  or  Bronchial  Lyimph-node  Lesions 
OR  Both  as  the  Most  Advanced  Lesions  in  a  Generalized  Tubercu- 
losis.— ^These  may  be  subdivided  into  two  classes: 

(a)  The  tuberculosis  in  the  lymph-nodes  was  more  advanced  than  that  in  the 
lungs.  In  25  cases  the  pulmonary  tuberculosis  was  of  the  acute  miliary 
variety,  but  the  bronchial  lymph-nodes  and  the  mesenteries  both  showed 
such  marked  cheesy  degeneration  that  it  was  not  possible  to  decide  macro- 
scopically or  microscopically  as  to  the  comparative  age  of  the  two.  In  3 
others  the  mesenteric  nodes  were  cheesy,  though  no  intestinal  ulceration 
had  occurred,  and  a  possible  intestinal  origin  is  admitted.  Eight  cases  showed 
normal  intestines  and  mesenteries,  though  liver  and  spleen  contained 
tubercles.  These  were  grouped  as  of  pulmonary  origin,  and  one  case  with 
intestinal  ulcers,  but  unchanged  mesenteries  was  looked  upon  as  a  secondary- 
intestinal  infection  from  swallowed  sputum. 

(b)  The  tuberculosis  in  the  lung  was  the  oldest  lesion.  In  83  cases  of  gen- 
eralized tuberculosis  in  which  the  lungs  were  the  seat  of  cheesy  nodules, 
cheesy  pneumonia,  or  cavity  formation,  the  mesenteric  lymph-nodes  were 
cheesy  as  well  as  the  bronchial  nodes,  and  ulcers  were  present  in  the  intes- 
tines. Twent3'"-six  eases  had  normal  mesenteries  and  intestines,  5  had 
cheesy  mesenteries  without  intestinal  lesions,  and  5  had  normal  mesenteries 
with  ulcers  in  the  intestines.  Again  the  probable  inhalation  cases  predom- 
inated. 

Group  II. 
1.  Cases  with  Intestinal  and  Mesenteric  Lymph-nodes  Alone  In- 
volved.— But  one  such  case  occurred.     It  was  that  of  a  boy,  twenty-two 
months  old.    Twelve  tuberculous  ulcers  were  found  in  the  jejunum  and 


428  SIXTH   INTERNATIONAL   CONGRESS    ON   TUBERCULOSIS. 

ileum,  only  one  involving  the  peritoneal  coat,  and  undergoing  cicatrization. 
But  four  ulcers  were  recent.  The  mesenteric  nodes  were  all  enlarged  and 
the  majority  contained  tuberculous  areas.  No  other  tubercles  were  found 
at  autopsy,  but  on  microscopical  examination  the  spleen  showed  very  recent 
ones  within  the  Malpighian  bodies.  From  the  mesenteric  nodes  of  this 
case  Dr.  Alfred  F.  Hess  isolated  tubercle  bacilli  of  the  human  type,  a  result 
in  keeping  with  Gaffky's  findings. 

2.  Cases  with  Intestinal  and  Mesenteric  Lesions  as  the  most 
Advanced  of  a  Partially  Generalized  Tuberculosis. — ^There  were  six 
such  instances: 

(a)  Boy,  two  years  old.  A  tuberculous  ulcer  in  the  Beyer's  patch  above 
the  ileocecal  valve  extended  to  the  peritoneal  coat,  to  which  a  cheesy  lymph- 
node  was  adherent;  two  other  and  younger  ulcers  were  in  the  ileum;  all 
mesenteries  were  swollen  and  the  majority  contained  cheesy  tubercles.  A 
few  tubercles  in  the  pia  mater  over  both  cerebral  hemispheres  were  the  only 
other  evidence  of  tuberculosis  in  the  body. 

(b)  Boy,  two  years  old.  One  early  tuberculous  ulcer  in  the  ileum  and  two 
in  the  cecum;  most  of  the  mesenteries  contained  cheesy  tubercles;  one  had 
become  softened;  miliary  tubercles  in  pia  mater,  liver,  and  lower  lobe  of 
right  lung;  bronchial  nodes  not  tuberculous. 

(c)  Boy,  fourteen  months  old.  One  ulcer  in  jejunum  involved  the  peri- 
toneum, and  two  in  the  ileum;  the  majority  of  the  mesenteries  were  cheesy 
and  one  had  broken  down;  recent  tubercles  in  spleen  and  liver. 

(d)  Boy,  nine  months  old.  Few  ulcers  in  jejunum  and  upper  ileum  of 
recent  date,  many  mesenteries  contained  cheesy  areas;  tubercles  in  liver, 
spleen,  and  kidneys;  several  bronchial  lymph-nodes  cheesy. 

(e)  Boy,  eleven  months  old.  Two  recent  tuberculous  ulcers  in  the  je- 
junum and  two  longer  healing  ones  in  the  ileum;  several  solitary  follicles  in 
the  cecum  were  cheesy.  Many  mesenteric  lymph-nodes  contained  a  cheesy 
tubercle,  and  one  a  calcareous  area.  One  bronchial  node  showed  a  small 
calcareous  spot,  and  another  several  cheesy  tubercles,  making  it  apparent 
that  the  case  was  of  both  aspiratory  and  digestive  origin. 

(/)  Boy,  one  year  old.  Admitted  with  stomatitis  and  dieharging  (opera- 
tion) wound  over  the  left  submaxillary  gland.  No  history  of  tuberculosis 
in  the  family.  All  the  cervical  lymph-nodes  became  enlarged;  stomatitis 
and  gingivitis  very  severe;  pulmonary  signs  only  ten  days  before  death. 
At  autopsy  all  the  cervical  nodes  were  found  to  have  undergone  cheesy  de- 
generation, and  the  left  submaxillary  gland  contained  cheesy  areas.  Miliary 
tubercles  were  present  in  both  lungs,  liver,  spleen,  and  omentum;  nine  tu- 
berculous ulcers  in  the  jejunum  and  ileum;  tubercles  in  bronchial  and  mesen- 
teric lymph-nodes,  but  no  large  areas  of  cheesy  degeneration.  This  must  be 
looked  upon  as  a  case  of  combined  deglutition  and  aspiration  tuberculosis. 


DISTRIBUTION  OF  LESIONS  IN  CHILDREN. — WOLLSTEIN.  429 

The  ingested  bacilli  affected  the  submaxillary  gland  and  the  cervical  lymph- 
nodes  by  way  of  the  lymphatics  of  the  mouth  and  pharynx,  and  the  intes- 
tines and  mesenteries  by  being  swallowed.  At  the  same  time  some  of  the 
bacilli,  aspirated  directly  into  the  lungs,  caused  the  pulmonary  and  bron- 
chial lymph-node  lesions.  Generahzation  by  the  blood-current  resulted 
from  both  the  cervical  and  the  mesenteric  nodes.  While  hemotogenous  in- 
fection of  the  lungs  and  bronchial  nodes  is  not  impossible,  the  peribronchial 
distribution  of  many  of  the  smallest  tuberculous  areas  in  the  lungs  speaks 
for  the  aspiration  method.  That  the  tonsils  and  gums  were  not  examined 
in  this  case  is  a  matter  of  great  regret. 

3.  Cases  Showing  Intestinal  and  Mesenteric  Lesions  as  the  Most 
Advanced  in  a  Completely  Generalized  Tuberculosis. — Only  two  cases 
occurred  in  this  series  in  which  the  intestinal  lesions  were  so  extensive  and 
advanced  that  the  possibility  of  their  being  the  earliest  of  a  completely 
generalized  tuberculosis  presented  itself. 

It  is  evident  that  in  our  entire  series  of  185  cases  there  are  but  7,  or  3|- 
per  cent.,  which  may  be  positively  classified  as  primary  intestinal  tubercu- 
losis.    Only  two  were  less  than  one  year  old. 

Medin  found,  among  595  autopsies  on  tuberculous  infants  under  one  year 
of  age,  but  6  cases  of  primary  intestinal  tuberculosis,  while  in  273  the  tuber- 
culous process  involved  the  lungs  and  bronchial  lymph-nodes  alone.  Ham- 
burger reports  that  in  four  years,  among  335  autopsies  on  children  with 
tuberculosis,  no  case  of  positive  primary  intestinal  infection  was  encountered, 
while  85  cases  were  primarily  bronchogenous.  German  authorities,  as  a 
rule,  agree  that  cases  of  primary  intestinal  infection  in  infants  and  young 
children  are  rare.  Heller  is  an  exception,  having  found  it  in  37.8  per  cent,  of 
his  cases.  EngUsh  statistics  on  this  subject  are  also  high,  Still  reporting 
29  per  cent.,  and  Thorne  30  per  cent.  Fiirst  estimates  that  about  160  cases 
of  primaiy  intestinal  tuberculosis  have  been  reported,  including  both  adults 
and  children. 

No  case  in  any  series  showed  involvement  of  the  mesenteric  lymph-nodes 
as  the  only  evidence  of  tuberculosis  at  autopsy.  In  twelve  instances  the 
mesenteries  had  undergone  cheesy  degeneration  without  the  presence  of 
ulcers  ici  any  part  of  the  intestinal  tract.  In  all  of  these  there  was  marked 
pulmonary  tuberculosis,  and  the  question  of  the  initial  lesion  remains  open, 
though,  according  to  Weichselbaum,  Weleminsky,  Von  Behring,  and  Cal- 
mette,  it  would  seem  to  be  in  the  mesenteric  lymph-nodes. 

The  ulcers  in  the  intestines  were  found  to  be  most  frequent  and  most 
advanced  in  the  lower  ileum,  especially  in  the  last  Peyer's  patch  above  the 
ileocecal  valve.  Ulcers  were  found  above  this  point  more  often  than  below 
it,  being  present  in  the  jejunum  and  ileum  more  frequently  (35)  than  in  the 
ileum  and  cecum  (28).    Seipel  also  found  that  the  colon  was  involved  less 


430  SIXTH   INTERNATIONAL   CONGRESS    ON   TUBERCULOSIS. 

than  the  jejunum  and  ileum.  The  jejunum,  ileum,  and  cecum  were  in- 
volved in  14  cases.  The  two  ends  of  the  intestinar  tube  were  scarcely  in- 
volved at  all,  ulcers  being  found  in  the  rectum  but  twice  and  in  the  duodenum 
four  times,  but  never  alone.  The  gastric  ulcers  noted  in  4  cases  were  super- 
ficial only.  So  also,  in  Seipel's  6  cases,  the  ulcers  in  the  stomach  were  super- 
ficial and  not  confluent. 

In  the  kidneys  young  miliary  tubercles  were  found  in  67  cases,  almost 
always  in  both  organs.  The  tubercles  were  for  the  most  part  few  in  number 
and  always  localized  in  the  boundary  zone  between  the  cortex  and  medulla, 
or  in  the  cortex  beneath  the  capsule;  in  either  case  of  hematogenous  origin. 
Very  small,  conglomerate,  cheesy  tubercles  were  found  in  5  cases,  but  again 
they  were  in  the  boundary  zone  and  encroached  on  both  cortex  and  medulla. 
The  calyces  and  pelvis  were  invariably  free  from  tuberculous  infection. 

The  pulmonary  lesions  varied  much,  there  being:  recent,  discrete,  mili- 
ary tubercles;  conglomerate  tubercles  forming  cheesy  nodules  of  smaller 
and  larger  size,  often  peribronchial  in  distribution;  larger  areas  of  cheesy 
pneumonia  with  or  without  cavity  formation  from  softening.  Sometimes 
all  these  varieties  were  found  in  the  lungs  of  a  single  case.  The  oldest  lesion 
in  the  lung  was  found  on  the  right  side  in  95  cases,  on  the  left  in  66,  and 
equally  in  both  lower  lobes  in  3.  The  right  upper  lobe  was  involved  rather 
more  often  than  the  middle  or  the  lower  lobes.  The  lungs  were  free  from 
tuberculosis  in  only  7  cases. 

Cavity  formation  was  noted  in  39  cases,  6  involving  more  than  one  lobe. 
The  cavities  occurred  more  often  on  the  right  (26)  than  in  the  left  lung  (19), 
and  more  often  in  the  upper  and  middle  than  in  the  lower  lobes. 

In  the  case  of  the  bronchial  lymph-nodes,  the  largest  were  found  on  the 
right  side  in  97,  on  the  left  in  34  cases.  This  preponderance  of  the  right 
over  the  left-sided  pulmonary  and  bronchial  lymph-node  tuberculosis  is 
attributable  to  the  purely  mechanical  fact  that  the  right  main  bronchus  is 
slightly  shorter  and  bends  away  from  the  trachea  less  than  does  the  left 
main  bronchus,  therefore  aspiration  is  facilitated  in  the  direction  of  the  right 
lung. 

The  mediastinal  lymph-nodes  were  markedly  affected  in  38  cases,  the 
cervical  in  6,  and  the  retroperitoneal  in  an  equal  number.  While  caseation 
was  the  rule  in  all  these  variously  situated  lymph-nodes,  and  suppuration 
was  more  common  in  the  bronchial  than  in  the  mesenteric  nodes,  calcareous 
change  was  found  but  once  in  a  mesenteric  and  five  times  in  a  bronchial 
lymph-node,  showing  that  the  tendency  of  the  tuberculous  process  in  the 
lymph-nodes  of  these  young  children  is  toward  progressive  degeneration 
rather  than  toward  healing.  Seipel  found  calcareous  deposits  in  but  2  of 
his  32  cases,  and  concludes  that  such  changes  are  unusual  in  infants;  and 
Schlossmann  calls  attention  to  the  absence  of  any  tendency  toward  healing 


DISTRIBUTION  OF  LESIONS  IN  CHILDREN. — WOLLSTEIN.  431 

in  cases  of  infantile  tuberculosis.  The  youngest  case  in  which  he  found  an 
attempt  at  encapsulation  in  a  pulmonary,  cheesy  mass  was  in  a  child  fifteen 
months  old.  Hamburger  found  no  case  of  healed  tubercles  in  children  under 
three  years  old. 

The  following  table  shows  the  locaUzation  of  the  lesions  in  the  individual 
organs : 

Pia  mater Tubercles  only,  21.     Tubercles  and  inflammatory  exudate, 

44. 
Brain Solitary    tubercle,    5;    largest  4x3x3  in  right  Sylvian 

fissure;   3  in  occipital,  1  in  frontal. 
Pleura Tubercles  60;    with  empyema,  9;    with  bloody  serous  fluid, 

10;   chronic  pleurisy,  29;   acute  fibrinous,  39. 
Lung Mihary  tubercles  only,  41;    miliary  tubercles  and  cheesy 

nodules,  54;    cheesy  pneumonia,  51;    cavities,  39. 
Pericardiiun Tubercles  pericarditis  at  base,  with  one  tubercle  on  pul- 
monary artery,  2. 
Heart Tubercle  in  wall  of  left  ventricle,  1 ;    in  papiUary  muscle 

of  left  ventricle,  1,'  in  endocardium,  1. 
Peritonexma General  tubercular  peritonitis,  3;  local  over  liver  and  spleen, 

6;   local  over  ulcers,  verj'-  many. 

Liver Tubercles,  157. 

Spleen Tubercles,  161. 

Stomach Ulcers,  single  in  3 ;  double  in  1 ;  all  superficial. 

Duodenum Ulcers,  with  jejunum,  1;    with  ileum  1;    with  ileum  and 

cecum,    1. 
Jejunum LUcers  alone,  7;   with  ileum,  35;   with  colon,  2;   with  ileum 

and  cecum,  14. 
Ileum Ulcers  alone,  21;   with  jejunum,  35;   with  cecum,  24;   with 

colon,  3;   cheesy  solitary  follicles,  1. 

Cecum Ulcers  alone,  5;   with  ileum,  24. 

Colon Ulcers  with  jejunum,  2;   with  ileiun,  3. 

Rectum Ulcers,  with  ileum,  2. 

Pancreas Cheesy  masses,  4. 

Suprarenals Tubercles,  5;    microscopical  only  in  1. 

Kidneys Tubercles,  67;    small  cheesy  masses,  5. 

Thymus Tubercles,  with  cheesy  degeneration,  5. 

Submaxillary Tubercles,  with  cheesy  degeneration,  5. 

Bronchial  nodes Tubercles,  with  cheesy  degeneration,  147;  suppuration,  24; 

calcareous  degeneration,  5. 
Mesenteric  nodes Tubercles,  with  cheesy  degeneration,  131;  suppuration,  3; 

calcareous  degeneration,  1. 

Cervical  nodes Tubercles,  with  cheesy  degeneration,  6. 

Retroperitoneal  nodes Tubercles,  with  cheesy  degeneration,  6. 

Mediastinal  nodes Tubercles,  with  cheesy  degeneration,  38. 

This  study  shows  how  comparatively  rare  primary  intestinal  tuberculosis 
was  in  this  series  of  infants  and  children  under  three  years  of  age,  and  that, 
even  when  due  allowance  has  been  made  for  all  doubtful  cases,  tuberculo.sis 
of  respiratory  origin  predominated  over  that  due  to  ingestion  of  the  bacilli 
in  these  young  subjects. 

I  am  indebted  to  Dr.  L.  Emmett  Holt  for  permission  to  make  use  of  the 
Babies'  Hospital  material  and  records. 


432  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 


BIBLIOGRAPHY 

Furst:    Intestinale  Tuberkulose-Infection.     Stuttgart,  1905. 

Weichselbaum:   JSechste  Internat.  Tuberkulose-Konferenz,  1907,  p.lL 

Fliigge:     Ibid.,  p.  46. 

Weleminsky:    Ibid.,  p.  119 

Medin:    Ibid.,  p.  120. 

Most:     Ibid.,  p.  132. 

Ravenel:     Ibid.,  p.  102. 

Herman;   Ibid.,  p.  103. 

Orth:     Ibid.,  p.    67. 

Orth:     Berliner  klin.  Wochens.,  1904,  xli,  265,  etc. 

Findel:     Zeits.  fiir  Hygiene,  1907,  xxxvii. 

Kossel:       Ibid.,  1896,  xx. 

Frobelius:     Jahrb.  fur  Kinderheilk. ,  1886,  p.  24. 

Bart  el  und  Neumann:    Quoted  by  Weichselbaum. 

Trepinski:    Quoted  by  Fiirst. 

Heller:   Deutsche  med.  Wochens.,  1902,  xxviii,  696. 

Still:     Practitioner,  1901. 

Thome:   Quoted  by  Fiirst. 

Von  Behring:    Berl.  klin.  Wochens.,  1906,  xl;    1904,  xli. 

Von  Behring:    Tuberculosis,  1907,  vi,  423. 

Hess:   Amer.  Jour.  Sciences,  1908,  cxxxvi,  183. 

Calmette  et  Gu^rin:   Annales  de  I'lnst.  Pasteur,  1906,  xx. 

Calmette:    Tuberculosis,  1907,  vi,  102. 

Hamburger;    AVien.  khn.  Wochens.,  1907,  xx,  1069. 

Seipel:    Zeits.  fiir  Hygiene,  1906,  xiii,  1. 

Schlossmann:    Tuberculosis,  1907,  vi,  79. 

Kuss:    Ibid.,  1907,  vi,  374. 

Gaffky:     Ibid.,  1907,  vi,  437. 

Beitzke:    Virchow's  Archiv,  1906. 

Spronck:    Tuberculosis,  1907,  vi,  101. 

Oettinger:    Zeits.  fur  Hygiene,  1908,  Ix,  557. 

Heyma:nn:   Ibid.,  1908,  be,  424.  490. 

Ostermann:   Ibid.,  1908,  Ix,  375. 

Reichenbach:  Ibid.,  1908,  Ix,  446. 


Die  Verteilung  tuberkuloser  Verletzungen  be|  jlg^^^^e  i  und  jungen 
Kindern.     Eine  Studie  auf  Grund  von  AutE^i^le&*«-(Wi)LLSTEiN.) 

Unter  1,131  Autopsien,  die  an  Kindern,  4  J.^JSEit  ?!^|r  J^^^^cht  wurden, 
zeigten  185  Tuber kulose.  Da  78  Prozent  alksr  j§tSti>gi^&i  Jk^\  Sauglingen 
unter  einem  Jahre  voUzogen  wurden,  zeigte  sitiji  «fe«f  tsi4f«8i^Sce^  se  Affektion 
von  12  Prozent  in  jenem  Alter.  Wahrend  dijjjfess^fes:  jl^iaaJS^  hres  hatten 
33  Prozent  aller  Falle,  die  zur  Autopsie  kamgB^p-U^J&^dfeBlai^  'VFSii  von  jenen, 
die  alter  als  zwei  Jahre  waren,  34  Prozent.  JRttswa^»-4-^?all8  veniger  als 
drei  Monate  alt,  der  jiingste  davon  sieben  WvJtJien,  Ea  k&m.  hdh  Fall  von 
angeborener  Tuberkulose  vor.  In  einem  Falle  war  die  canKige  tul  lerkulose 
Verletzung  in  den  Broncliialdriisen  gefundrai  wc«ti«oi;  in  vier  war  dLe  Lunge 
allein  in  Mitleidenschaft  gezogen,  und  in  13  die  I^ngan-und  Bronchia'  Iriisen. 
Es  waren  7  Fiille  primarer  Infektion  des  Verilaaungstraktes  vo?  landen, 
einschliesslich  zweier  gemischten  Ursprang€S5  dor  Sohlucfc- ynd  Atu.ungsor- 
gane.     Von  den  vorgeschritteneren  allgeineineten  Fdlesgabenmir  ^wei  eine 


DISTRIBUTION  OF  LESIONS  IN  CHILDREN. — WOLLSTEIN.  433 

Erscheinung  von  Moglichkeit  eines  Ursprunges  in  den  Gedarmen,  wahrend 
40  im  Respirationstrakte  begannen.  In  der  Mehrheit  ausgedehnt  allge- 
meiner  Falle  von  Tuberkulose  bei  jungen  Kindern  ist  es  zweifelhaft,  den 
genauen  Eintrittspunkt  zu  finden.  Obwohl  die  Lungen  haufiger  als  irgend 
welche  anderen  Organe  in  Mitleidenschaft  gezogen  sind,  beweist  dies  eher 
ihre  besondere  Pradisposition  zu  Tuberkulose,  als  ihre  primare  Infektion. 
Nichtsdestoweniger  iiberwiegen  die  Falle  respiratorischen  Ursprunges  jene, 
wo  der  Ursprung  in  den  Verdauungsorganen  zu  finden  ist. 


La  Distribution  des  Lesions  tuberculeuses  chez  les  B6h6s  et  chez  les  petits 
Enfants.     Etude  fondee  sur  Autopsies. — (Wollstein.) 

De  1,131  autopsies  d'enfants  ages  de  moins  de  quatre  ans,  185  pr^sen- 
taient  la  tuberculose.  Du  nombre  total  d'autopsies,  78  pour  cent  etaient 
sur  des  enfants  ages  de  moins  d'un  an  et  de  ces  enfants  12  pour  cent  etaient 
atteints  de  tuberculose.  De  tous  ceux  qui  moururent  pendant  la  seconde 
annee  de  leur  vie,  33  pour  cent  avaient  la  tuberculose,  et  de  ceux  plus  ages 
que  deux  ans,  34  pour  cent.  Quatre  enfants  avaient  moins  de  trois  mois, 
le  plus  jeune  etant  age  de  sept  semaines.  Nul  cas  de  tuberculose  congenital 
ne  fut  observe.  Dans  un  cas  la  seule  lesion  tuberculeuse  se  trouva  dans  les 
glandes  bronchi  ales;  dans  quatre,  les  poumons  seulement  etaient  atteints; 
dans  treize,  les  poumons  et  les  glandes  bronchiales.  II  y  avait  sept  cas  d'in- 
fection  priraaire  de  la  voie  alimentaire,  y  compris  deux  cas  a  origine  alimen- 
taire  et  respiratoire  mixte.  Parmi  les  cas  avanc^s  et  les  cas  de  tuberculose 
generale,  deux  seulement  paraissaient  etre  d'origine  intestinale,  tandis  que 
dans  quarante  la  maladie  avait  commence  dans  la  voie  respiratoire. 

Dans  la  plupart  des  cas  de  tuberculose  generale  ^tendue  chez  les  petits 
enfants  il  n'est  pas  possible  de  preciser  la  porte  d'entree.  Quoique  les  pou- 
mons soient  atteints  plus  frequemment  que  tous  les  autres  organes,  ce  fait 
demontre  leur  predisposition  a  la  tuberculose  plutot  que  leur  infection  pri- 
maire.  Tout  de  meme  les  cas  d'origine  respiratoire  I'emportent  sur  ceux 
dans  lesquels  les  bacilles  s'introduisent  par  la  voie  alimentaire. 


TUBERCULOUS   PULMONARY  CAVITIES  IN  INFANTS. 

By  C.  Y.  White,  M.D., 

Pathologist  to  The  Children's  Hospital  of  Philadelphia, 

AND  Howard  Childs  Carpenter,  M.D., 

Assistant  Pathologist  to  the  Children's  Hospital  of  Philadelphia. 


In  reviewing  the  literature  on  the  subject,  the  fact  impresses  itself  that 
many  writers  on  diseases  of  infants  treat  the  subject  in  a  very  indefinite 
manner.  Some  do  not  refer  to  it ;  while  others  speak  of  it  as  if  tuberculous 
cavities  in  infants  followed  the  general  course  of  events  so  frequently  seen 
in  the  adult.  This  is  somewhat  surprising,  because  most  of  the  authors 
who  have  written  especially  on  this  subject  point  out  how  difficult  it  is  to 
make  an  ante-mortem  diagnosis  of  a  cavity  in  comparison  to  the  condition 
in  later  life.  We  have  had  difficulty  in  selecting  our  cases  from  this  liter- 
ature, because  many  authors  have  failed  to  make  the  distinction  between 
infancy  and  childhood.  In  this  paper  we  have  accepted  the  customary  age 
limit  of  two  years  for  infancy;  consequently,  we  have  only  selected  those 
cases  from  the  literature  in  wliich  we  have  either  been  able  to  ascertain 
definitely  their  age,  or  at  least  believed  they  were  under  two  years. 

For  our  purpose  the  subject  may  be  divided  into  the  following  heads: 
(1)  The  frequency  of  cavity  formation  in  the  lungs  of  infants.  (2)  The 
pathology  of  the  condition.  (3)  The  location  of  the  cavities  in  the  lungs. 
(4)  The  report  of  six  cases. 

1.  The  Frequency  of  Cavity  Formation  in  the  Lungs  of  Infants. — 
From  the  literature  we  have  been  able  to  find  special  mention  of  cavity 
formation  in  a  number  of  instances.  These  cases  have  been  sifted  from 
general  discussions  of  the  subject,  rather  than  special  reports  of  cases.  We 
believe  many  cases  have  not  been  recorded,  because  observers  have  not 
deemed  it  of  sufficient  importance  to  report  them.  Clinically,  in  the  vast 
majority  of  cases  cavity  formation  in  the  lungs  of  infants  is  entirely  over- 
looked. We  believe,  therefore,  that  by  calling  attention  to  its  frequency  and 
localization,  cavities  should  be  more  often  recognized  during  life. 

Leroux,  in  analyzing  Parrot's  cases,  found  cavity  formation  present  in 
57  cases  out  of  219  autopsies  on  patients  under  three  years  of  age;  that  is, 
26  per  cent,  of  the  cases.  He  particularly  mentions  5  of  these  cases  which 
were  under  three  months  of  age,  but  unfortunately  no  reference  is  made  to 
the  number  under  two  years.  Warthin  and  Cowie  quote  the  following  five 
authors:    Huguenin,  as  reporting  2  cases,  a  seven-month  premature  infant 

434 


PULMONARY  CAVITIES  IN  INFANTS. — WHITE  AND  CARPENTER.         435 

and  an  infant  seven  weeks  old;  Berti,  as  reporting  1  case  nine  days  old; 
Demme,  as  reporting  1  case  eleven  weeks  old;  Queyrat,  as  reporting  1  case 
three  months  old ;  Flesch,  as  reporting  8  cases  out  of  500  autopsies  on  chil- 
dren in  the  early  months  of  life.  Demme  reports  1  case,  aged  four  weeks. 
F.  Weber  reports  1  case,  aged  three  months.  Henock  reports  5  cases,  ages  four, 
seven,  eight,  ten,  and  eighteen  months.  Comby  reports  four  cases,  ages  four, 
six,  eight,  and  nine  months.  Deliarde  reports  1  case,  age  six  months,  and 
speaks  of  the  rareness  of  cavity  at  this  age.  Symes  and  Fisher,  in  reporting 
500  deaths  at  various  ages  from  tuberculosis,  refer  to  2  cases  with  cavities; 
five  and  eight  months  old.  Shennan  reports  23  cases  having  cavities,  in  a 
total  of  355  cases,  that  is,  6.5  per  cent.  Carmichael  reports  2  cases,  ages 
eight  and  fifteen  months.  Toulmin  reports  1  case,  four  months  old.  Donkin 
reports  1  case,  aged  one  year.  Fry  and  Shaw  report  1  case,  twelve  months  old. 
Price-Jones  reports  3  infants,  thirteen,  sixteen,  and  twenty-two  months  old. 
J.  Lewis  Smith  reports  1  case,  aged  seventeen  months.  Green  reports  6  cases, 
under  two  years.     Barthez  and  Sanne  report  10  cases,  under  two  years. 

Zuber  says,  "All  authors  agree  that  cavities  are  rarer  in  children  than  in 
adults";  and  Baginski  states,  "chronic  tuberculosis  with  cavity  formation 
in  young  children  in  characteristic  form,  as  in  the  adult,  is  an  infrequent 
disease."  Other  authors,  as  Rotch,  i\Ionti,  Jacobi,  Still,  Osier,  and  Ashby, 
speak  in  general  terms  of  the  rarity  of  cavities  in  infants  under  two  years 
compared  with  older  children.  The  above  mentioned  cases,  in  all  likelihood, 
do  not  represent  the  observations  of  these  men  as  to  the  frequency  of  cavity 
formation,  but  simply  some  of  the  cases  wliich  they  have  had  occasion  to 
refer  to  in  reports.  On  the  other  hand,  the  following  observers  have  found 
cavitation  in  infancy  of  more  frequent  occurrence. 

Northrup  in  a  personal  communication  says:  "Tuberculous  cavities 
are  not  rare  in  infants  as  young  as  a  few  weeks  even.  They  follow  the  law 
which  would  seem  to  apply  to  adults.  .  .  .  The  lesion  is  common.". 
Rilliet  and  Barthez  report  cavities  in  the  proportion  of  1  to  3,  in  patients 
from  one  to  two  and  a  half  years  old.  Holt  says:  "Areas  large  enough  to 
deserve  the  name  cavities  were  present  in  35  of  72  autopsies  upon  tuber- 
cular patients,  two  years  old  and  under."  De  Rothschild  states  that  pul- 
monary cavities  are  observed  in  one-third  of  the  cases  from  one  to  two  and  a 
half  years.  Hervieux  reports  that  one-fifth  of  the  cases  in  the  course  of 
the  first  year  of  life  have  pulmonary  cavities.  J.  Francis  Condie  went  so 
far  as  to  say,  "Tuberculous  cavities  are  much  more  frequent  in  very  young 
children  than  in  adults."  Warthin  and  Cowie  quote  Weber  as  making  the 
statement  that  he  had  many  times  observed  tuberculous  cavities  of  the  size 
of  half  a  lobe  in  children  under  the  age  of  three  months. 

From  the  above  r6sum6  of  the  literature,  it  will  be  seen  that  the  frequency 
of  cavity  formation  in  infancy  has  been  observed  by  some  in  a  high  per- 


436  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

centage  of  cases;  while  by  others,  it  has  been  found  but  rarely.  From  the 
few  cases  which  we  have  been  able  to  collect  from  the  literature,  the  earliest 
case  occurred  in  an  infant  premature  at  the  seventh  month;  while  the  ma- 
jority were  found  beyond  the  tliird  month,  with  increasing  frequency  toward 
the  end  of  infancy. 

In  order  to  estimate  the  frequency  of  tuberculous  cavities  in  infants  at 
the  Children's  Hospital  of  Philadelphia,  the  records  for  the  past  seventeen 
years  have  been  reviewed.  We  have  found  that  during  this  time  4518  in- 
fants have  been  admitted  to  the  wards  of  the  hospital.  Of  this  number, 
1140  infants  have  died,  a  mortality  record  of  25.2  per  cent,  of  the  admissions. 
Of  the  total  number  of  deaths,  6.5  per  cent,  were  tuberculous.  However, 
these  figures  are  only  approximate,  because  only  one-third  of  the  children 
dying  were  autopsied.  Again,  if  we  consider  the  number  of  tuberculous 
autopsies  compared  with  the  total  number  of  admissions  during  tliis  period, 
it  will  be  found  that  75  cases,  or  1.6  per  cent.,  were  tuberculous.  It  will  be 
seen  from  the  statistics  of  autopsy  that,  with  us,  tuberculosis  in  infants  under 
two  years  of  age  is  infrequent.  This  is  partly  explained  by  the  fact  that 
the  majority  of  infants  coming  to  the  hospital  have  some  form  of  advanced 
gastro-intestinal  disorder.  If  the  actual  number  of  cases  of  gastro-intes- 
tinal  disease  be  studied  from  our  autopsy  records,  it  will  be  seen  that  155 
cases  out  of  the  371  autopsies  performed  (or  41.7  per  cent.)  were  grouped 
under  this  head.  Therefore,  if  these  cases  of  advanced  gastro-intestinal 
diseases  be  omitted  from  our  comparison,  it  will  be  seen  that,  of  the  remain- 
ing autopsies  (216),  there  w^ere  75  cases,  or  34.5  per  cent.,  tuberculous. 
This  latter  comparison  really  emphasizes  the  high  mortality  of  gastro- 
intestinal disorders  (41.7  per  cent.)  far  more  than  it  does  of  tuberculosis 
(34.7  per  cent.)  at  this  age.  For  we  believe,  from  the  clinical  aspect  at 
least,  that  our  former  percentage  of  1.6  per  cent,  of  fatal  cases  is  nearer  the 
truth,  as  far  as  tuberculosis  at  this  age  is  concerned.  Below  we  have  tab- 
ulated the  ages  of  tuberculous  infants  coming  to  autopsy: 

First  Year.  Second  Yeah. 

One  month  old 0  cases.  Twelve  months  old 7  cases. 

Two  months  old 1  case.  Thirteen  months  old 3  cases. 

Three  months  old 2  cases.  Fourteen  months  old 6  cases. 

Four  months  old 1  case.  Fifteen  months  old 4  cases. 

Five  months  old 5  cases.  Sixteen  months  old 3  cases. 

Six  months  old 9  cases.  Seventeen  months  old 3  cases. 

Seven  months  old 5  cases.  Eighteen  months  old 6  cases. 

Eight  months  old 3  cases.  Nineteen  months  old 4  cases. 

Nine  months  old 2  cases.  Twenty  months  old 1  case. 

Ten  months  old 5  cases.  Twenty-one  months  old ....    1  case. 

Eleven  months  old 2  cases.  Twenty-two   months  old ...   0  cases. 

—  Twenty-three  months  old  .  .   2  cases. 

35  cases.  — 

40  cases. 

Number  of  autopsies  on  tuberculous  infants  under  one  year 35 

Number  of  autopsies  on  tuberculous  infants  between  one  and  two  years .  40 

Total  number  of  autopsies  on  tuberculous  infants  under  two  years. . .  .75 


PULMONARY  CAVITIES  IN  INFANTS. — WHITE  AND  CARPENTER.  437 

To  study  the  frequency  of  cavity  formation  in  the  lungs  of  infants  d3dng 
of  tuberculosis,  we  have  gone  over  the  records  of  the  Children's  Hospital, 
and  found  that  cavity  formations  were  present  in  12  cases  of  the  75  dying 
of  tuberculosis,  or  16  per  cent. 

As  was  stated  above,  we  encountered  difficulty  in  trying  to  estimate 
this  frequency  from  the  Uterature.  In  only  a  few  reports  were  actual  state- 
ments as  to  percentage  obtainable.  In  our  cases  1  in  6  showed  excavations; 
which  is  a  lower  percentage  than  the  observations  of  the  quoted  authors. 
Nevertheless,  it  will  be  seen  even  in  our  cases  that  cavity  formation  is  not 
uncommon. 

If  we  consider  the  frequency  of  this  process  in  older  children,  as  compared 
to  our  findings  in  infants,  it  will  be  seen  that  in  the  former  cavitation  is  not 
only  more  frequent,  but  follows  the  rule  applying  to  adults.  The  usual 
explanation  of  this  condition  is  the  greater  resistance  offered  as  the  child 
grows  older,  allowing  the  process  to  become  of  a  more  chronic  nature,  and 
thus  giving  mixed  infections  greater  opportunity. 

The  ages  of  the  cases,  under  two  years  of  age,  with  tuberculous  cavities, 
at  the  Children's  Hospital,  were  as  follows: 

Five  months  old 1  case. 

Six  months  old 4  cases. 

Seven  months  old 1  case. 

Eleven  months  old   1  case. 

Twelve  months  old 1  case. 

Fifteen  months  old 2  cases. 

Seventeen  months  old 1  case. 

Nineteen  months  old 1  case. 

Total 12  cases. 

2.  Pathology  of  the  Condition. — In  considering  the  pathology  of 
tuberculosis  at  this  age,  a  brief  r^sum6  of  the  types  of  lesions  may  be  of 
some  value.  It  is  not  our  purpose,  however,  to  consider  in  detail  these 
various  lesions.  Briefly,  then,  the  general  pathology  of  tuberculosis  at  this 
age  may  be  divided  into  three  types:  (a)  Acute  miliary  tuberculosis;  (6) 
chronic  tuberculosis  with  fibrous  changes;  (c)  bronchocaseous  pneumonic 
tuberculosis. 

(a)  Acute  miliary  tuberculosis,  or  acute  disseminated  mihary  tuberculosis 
of  the  lungs,  is  considered  rare  by  the  majority  of  authors  at  this  early  age 
of  Ufe.  When  it  does  occur,  the  miliary  tubercles,  either  gray  or  yellowish- 
gray  in  color,  are  found  scattered  throughout  both  lungs,  and  to  a  less  extent 
in  other  organs  of  the  body.  These  tubercles  vary  in  size  and  number  ac- 
cording to  the  degree  of  infection  and  the  duration  of  the  disease. 

(b)  Chronic  tuberculosis  with  fibrous  changes  in  the  lungs  can  be  very 
briefly  considered  here.  This  type  of  tuberculosis  at  first  is  generally 
locahzed  to  a  small  area  or  areas,  and  the  process  is  accompanied  by  the 


438  SIXTH   INTERNATIONAL   CONGRESS    ON   TUBERCULOSIS. 

production  of  fibrous  tissue.  The  process  may  consist  of  caseating  areas 
containing  small  cavity  formations,  surrounded  by  more  or  less  fibrous 
tissue.  Distinct  chronic  tuberculosis  of  the  lungs  with  cavity  formation 
within  the  first  two  years  of  life,  compared,  to  the  adult  type  of  the  disease, 
is  rarely  found  at  autopsy. 

(c)  The  caseous  bronchopneunwnic  type  of  tuberculosis  is  the  most  fre- 
quent form  of  the  disease  in  the  lungs  at  this  age.  It  runs  a  more  or  less 
subacute  course,  and  is  almost  always  fatal.  The  advanced  caseous  lesions 
are  usually  confined  to  one  lobe,  or  to  one  lung,  with  less  marked  lesions  in 
the  other  lobes  or  lung.  In  a  section  of  a  lung  showing  tuberculous  lesions 
of  tliis  type  there  are  usually  large  caseous  areas  with  intervening  areas 
of  bronchopneumonia,  congested  lung  tissue,  or  normal  lung  tissue.  The 
multiple  lesions  so  frequently  seen  in  these  cases  have  their  origin  from  some 
older  process,  and  are  disseminated  by  way  of  the  blood,  the  lymphatics,  or 
from  the  effect  of  insufflation.  They  increase  in  size  by  peripheral  ex- 
tension, and  by  the  fusion  of  closely  situated  smaller  areas.  This  method 
of  extension  is  especially  to  be  seen  when  the  lesions  are  near  the  apposing 
surfaces  of  the  lobes,  and  it  is  not  uncommon  to  see  the  greater  part  of  one 
lobe,  with  the  adjacent  parts  of  another  lobe,  involved  in  the  caseous  proc- 
ess. The  interlobar  pleura  in  such  cases  is  obliterated  by  the  tuberculous 
process,  or  stands  out  prominently  as  a  fibrous  band  stretched  across  the 
caseous  area.  It  is  in  these  large  caseous  areas  that  cavity  formation  most 
frequently  begins  at  this  age.  Cavities  are  usually  the  result  of  acute 
softening  of  the  central  part  of  the  caseous  mass,  and  when  this  softened  area 
communicates  with  a  bronchus,  the  fluid  parts  are  thrown  off,  leaving  a 
space  or  cavity.  The  softening  of  the  caseous  mass  is  generally  the  result 
of  a  secondary  infection,  and  is  usually  due  to  the  streptococcus  pyogenes, 
staphylococcus  pyogenes  aureus  and  albus,  the  micrococcus  tetragenus,  or 
the  diplococcus  pneumoniae.  A  pure  tuberculous  process,  as  a  rule,  does  not 
tend  to  liquefy,  it  being  a  drier,  harder,  and  more  cheesy  process.  This  in 
itself  would  explain  the  infrequent  cavity  formation  in  our  group  of  cases. 

In  examining  the  lungs  of  this  type  of  tuberculosis,  one  frequently  finds 
small  softened  areas  in  these  caseous  lesions.  These  have  been  recorded  by 
some  authors  as  instances  of  cavities;  and  in  the  course  of  time  they  in  all 
likeUhood  would  become  cavities.  We  have  not  included  such  areas  as 
cavities  in  our  cases,  because  an  ante-mortem  excavation  had  not  existed. 

The  walls  of  the  cavities  are  usually  irregular  in  outline,  and  somewhat 
darker  in  color  than  the  surrounding  lung  tissue,  especially  when  thq  cavity 
has  existed  for  some  time.  A  distinct  communication  with  a  bronchus  may 
be  found  on  some  part  of  the  cavity  wall,  though  it  may  be  small  and  difficult 
to  locate.  The  size  of  the  cavity  varies  usually  with  the  chronicity  of  the 
case  and  the  size  of  the  caseous  lesion.     From  the  microscopical  examination 


PULMONARY  CAVITIES  IN  INFANTS. — WHITE  AND  CARPENTER.  439 

of  these  cases  it  would  seem  that  the  process  is  rapid,  as  the  walls  of  the 
cavity  consist  almost  entirely  of  caseous  material.  Fibrous  tissue  formation 
in  the  walls  of  the  cavity  does  not  take  place  to  any  great  degree,  in  this 
group  of  cases,  compared  to  the  formation  of  this  tissue  in  the  adult. 

The  fact  that  in  early  infancy  the  tuberculous  process  in  the  lung  is 
generally  of  an  extensive  bronchocaseous  type,  running  an  acute  or  a  subacute 
course,  explains,  in  part,  the  absence  of  fibrous  tissue  in  the  lesions.  It 
is  a  fact  that  the  younger  the  individual,  the  more  extensive  the  involve- 
ment and  the  more  acute  the  course.  This  statement  is  the  result  of  au- 
topsy examinations,  and  does  not  take  into  consideration  the  numerous 
infections  with  the  tubercle  bacillus  which  undoubtedly  occur  in  early  life, 
and  are  held  in  abeyance,  or  cured.  As  many  of  these  latter  cases  are  not 
diagnosed,  the  occurrence  of  the  disease  can  only  be  surmised  from  the  wide- 
spread prevalence  of  tuberculosis.  It  is  only  in  the  susceptible  cases  at 
this  age  that  the  process  becomes  diffuse,  and,  after  an  acute  or  subacute 
course,  ends  fatally.  It  may  also  be  noted  here  that  in  infants  dying  of 
tuberculosis  the  lungs  are  involved  in  100  per  cent,  of  the  cases. 

3.  The  Location  of  the  Cavity. — ^The  literature  on  the  subject  of  the 
localization  of  the  cavity  is  not  very  extensive.  The  majority  of  authors 
state  that  cavity  formation  usually  takes  place  in  the  lower  lobes,  and  gen- 
erally at  the  root  or  central  part  of  the  lung.  D.  Francis  Condie  says: 
"There  is  an  important  modification  that  should  guide  the  practitioner 
when  he  seeks  to  determine  the  existence  of  a  cavern  in  young  children, 
viz.,  that  under  five  years  of  age  the  cavernous  excavation  is  generally 
seated  in  the  lower  or  middle  lobes,  and  is  almost  confined  to  one  side  of  the 
chest."  James  M.  Cooley  found  cavities  in  infants  much  more  frequently 
in  the  inferior  lobes,  and  most  often  on  the  right  side.  Zuber  also  found 
the  right  lung  most  commonly  affected,  and  generally  only  one  lung.  Both 
J.  Walter  Carr  and  S.  Vere  Pearson  have  observed  that  in  infants  the  usual 
location  of  cavities  is  at  the  root  or  central  portion  of  the  lobe.  Berti  and 
Demme  each  report  cases  with  a  cavity  in  the  lower  lobe  of  the  right  lung. 
Fry  and  Shaw  report  a  case  with  a  cavity  in  the  lower  lobe  of  the  left  lung. 
Price- Jones  reported  an  infant  with  cavities  in  the  same  location;  but  re- 
port another  case  with  a  cavity  in  the  upper  lobe  of  the  left  lung.  Huguenin 
reported  an  infant  with  a  cavity  at  the  apex  of  the  left  lung. 

Henock  reported  four  cases,  as  follows : 

An  infant,    4  months  old,  right  upper  lobe  (two  cavities). 

li  <(  n  u  t(  u  n  II 

"       "         8       "         "        "         "        "     (two  cavities). 

"        "        18       "         "     both  lungs,  numerous  small  cavities. 

J.  Lewis  Smith  reported  one  case  at  seventeen  months,  with  cavities  in 
both  upper  lobes. 


440  SIXTH   INTERNATIONAL  CONGRESS   ON   TUBERCULOSIS. 

P.  Bennis  Green  reported  six  cases  as  follows : 

An  infant,  2  years  old,  summit  of  right  lung. 
"        "        "     "       "     middle  lobe  of  right  lung. 
"       "      "       "     upper  lobe  of  left  lung. 
"      "       "     lower  lobe  of  left  lung. 

On  the  other  hand,  Eustace  Smith  says:   "The  masses  situated  nearest 
the  apex  are  commonly  the  earliest  to  liquefy,  but  not  always." 
Barthez  and  Sanne,  in  77  cases  of  cavity  in  infants  found : 

Cavities  within  the  right  lung 47 

"     upper  lobe 34 

"     middle  lobe 9 

"     lower  lobe 16 

Cavities  within  the  left  lung 51 

"    upper  lobe 51 

"    lower  lobe 18 

The  location  of  the  cavities  in  the  cases  at  the  Children's  Hospital  may 
be  tabulated  as  follows : 

Left  lung 6 

"       "     upper  lobe 2 

"       "     anomalous  middle  lobe 1 

"       "     lower  lobe 2 

"       "     location  not  specified 1 

Right  lung 6 

"         "     upper  lobe 2 

"     middle  lobe 1 

"         "     lower  lobe 3 

To  summarize:  Upper  lobes,  4;  middle  lobes,  2;  lower  lobes,  5;  location 
of  cavity  not  specified,  1. 

This  small  table  shows  the  greater  frequency  of  tuberculous  cavities  in 
the  middle  and  lower  lobes  in  infancy  in  our  cases.  If  we  consider  the  loca- 
tion of  cavity  formation  in  our  own  cases,  and  of  those  quoted  in  the  Htera- 
ture,  it  will  be  seen  that  the  lesion  does  not  occur  at  the  same  location  as  it 
does  in  adults.  In  the  majority  of  cases  cavities  in  infants  are  deeply  seated, 
and  usually  at  the  root  of  the  lung.  In  our  cases  cavities  occurred  more 
frequently  in  the  lower  and  middle  than  in  the  upper  lobes. 

4.  Of  the  twelve  autopsies  performed  on  cases  of  tuberculous  pulmonary 
cavities  in  infants  at  the  Children's  Hospital  in  the  last  sixteen  and  three- 
quarter  years,  six  have  come  under  our  personal  observation.  It  is  these 
six  cases  we  desire  to  report : 

Case  I. — Lillian  R.,  aged  six  months,  was  admitted  to  the  hospital  on 
April  4,  1904.  The  family  history  was  negative.  The  infant  had  been  fed 
at  different  times  on  breast-milk,  condensed  milk,  and  cows'  milk.  Although 
patient  had  always  been  a  delicate  child,  she  had  never  had  any  serious  ill- 
ness.    She  was  taken  sick  three  weeks  before  admission  to  the  hospital. 


PULMONARY  CAVITIES  IN  INFANTS. — WHITE  AND  CARPENTER.  441 

with  diarrhea,  weakness,  and  sweating  at  night.  Four  days  before  admission 
developed  a  cough,  coughing  severely  at  times,  and  became  extremely  weak. 
The  physical  examination  disclosed  a  bronchopneumonia  in  an  emaciated, 
rachitic  infant.  The  patient  became  weaker,  the  bowels  continued  loose, 
and  the  temperature  irregular,  until  the  child  died,  nine  days  after  admis- 
sion. 

Pathological  diagnosis:  Bronchocaseous  pulmonary  tuberculosis.  Tu- 
berculous enteritis.     Tuberculosis  of  liver  and  spleen. 

The  left  pleura  shows  a  few  tubercles  on  its  parietal  surface.  The  left 
lung  measures  11^  by  6^  by  3  cm.  and  weighs  70  grams.  It  is  everywhere 
studded  with  grayish-yellow  tubercles,  most  of  them  small  (millet-seed), 
some  few  attaining  to  larger  size.  Portions  of  the  lower  lobe  are  so  thickly 
studded  with  tubercles  as  to  sink  in  water.  The  lung  is  mottled  gray  and 
dark  red.  The  air-contents  is  especially  diminished  in  the  lower  lobe. 
There  is  h5^3ostatic  congestion  in  the  lower  lobe  and  the  lower  part  of  the 
upper  lobe.  The  surface  section  is  granular,  moist  and  glistening,  of  a 
mottled  grayish  color.  Crepitation  is  diminished,  while  the  consistency  is 
firm  and  tenacious,  with  a  blood-stained  fluid  exuding.  The  right  lung 
weighs  108  grams.  The  air-content  is  practically  absent  in  the  lower  lobe, 
and  portions  of  all  three  lobes  sink  in  water.  The  lower  lobe  is  consoli- 
dated, but  is  less  thickly  studded  than  the  left  lung  with  miliary  tubercles. 
The  lower  part  of  the  middle  lobe  also  shows  pneumonia.  The  upper  part  of 
the  middle  lobe  and  the  upper  lobe  show  much  more  thickly  scattered  tuber- 
cles. There  is  a  cavity  in  the  lower  portion  of  the  lower  lobe  posteriorly, 
containing  caseous  detritus.  The  bronchial  lymph-glands  are  every\vhere 
enlarged.  There  is  tuberculosis  of  the  cervical,  mediastinal,  and  retro- 
peritoneal glands.  Miliary  tubercles  in  liver  and  spleen.  Also  a  fatty  liver, 
and  chronic  follicular  colitis. 

Case  II. — John  T.,  aged  fifteen  months,  colored,  was  admitted  to  the 
hospital  on  April  5,  1904.  The  family  history  was  entirely  negative.  Baby 
was  fed  since  birth  on  skimmed  milk.  Until  four  days  before  admission  to 
the  hospital  he  was  apparently  well.  During  these  four  days  he  had  profuse 
sweating,  cough,  fever,  and  evident  pain  on  touching  the  anterior  chest  wall. 
Examination  showed  a  diffuse  bronchopneumonia.  Infant  died  three  days 
after  admission. 

Pathological  diagnosis:  Caseous  bronchopneumonia.  Miliary  tubercu- 
losis of  lungs,  pleura,  omentum,  hver,  spleen,  and  the  hepatic,  mesenteric, 
bronchial,  and  retropharyngeal  glands. 

The  left  lung  measures  11^  by  7^  by  3h  cm.  and  weighs  71  grams.  The 
color  is  mottled  gray;  the  air-contents  is  diminished  in  the  lower  lobe,  but 
in  the  upper  it  is  normal.  In  the  upper  part  of  the  middle  lobe  there  is  a 
cavity  2^  cm.  in  diameter,  surrounded  by  tuberculous  caseous  infiltration. 
The  walls  of  the  cavity  are  irregular  and  bordered  here  and  there  with  tuber- 
culous caseous  masses.  The  contents  of  the  cavity  are  purulent.  The 
pleura  directly  over  the  above  area  is  adherent,  with  recent  fibrinous  ad- 
hesions to  the  chest  wall;  on  breaking  these  adhesions  the  cavity  was  rup- 
tured. Scattered  througli  the  lower  lobe,  and  less  in  the  upper  lobe,  are 
many  yellow  tubercles.  The  right  pleura  shows  a  few  pearly  tubercles  on 
the  parietal  layer.  The  right  lung  measures  10^  by  8  by  2\  cm.  and  weighs 
49  grams.    This  lung  is  not  affected  except  for  a  number  of  yellow  tubercles. 


442  SIXTH  INTERNATIONAL  CONGRESS   ON  TUBERCULOSIS. 

Case  111. — ^^loses  C,  aged  six  months,  colored,  was  admitted  to  the 
hospital  January  8,  1905.  The  father  and  mother  are  living  and  well;  they 
have  had  two  children,  the  patient  and  one  other  child,  wliich  is  dead. 
The  cause  of  death  given  was  teething  (?).  The  patient  had  been  breast-fed 
up  to  the  time  of  admission.  He  has  always  been  well  until  three  months 
before  coming  to  the  hospital;  during  these  three  months  the  infant  had  a 
severe  cough,  but  two  days  before  admission  cough  became  much  worse  and 
great  quantities  of  mucus  were  coughed  up.  The  examination  elicited  the 
physical  signs  of  a  bronchopneumonia.  The  temperature  was  not  hectic. 
In  two  days  after  admission  the  infant  died. 

Pathological  diagnosis:  Caseous  bronchopneumonia.  General  miliary 
tuberculosis.  Tuberculosis  of  liver  and  spleen  and  of  the  bronchial  and  mes- 
enteric lymph-glands. 

The  left  lung  weighs  145  grams.  The  entire  lower  lobe  and  the  lower 
part  of  the  upper  lobe  is  consolidated.  There  is  a  large  cavity  3  by  2  by  4  cm. 
in  the  upper  third  of  the  lower  lobe  posteriorly.  It  is  superficial,  and  in 
one  place  a  tliickened  pleura  forms  part  of  the  wall.  The  blood-vessels  and 
bronchi  bridge  across  the  cavity  and  the  walls  are  very  irregular  and  dark 
in  color.  A  small  cavity  \  by  |  by  ^  cm.  is  also  found  on  the  lower  surface 
of  the  lower  lobe.  There  is  an  extensive  obliterative  diaphragmatic  pleu- 
risy at  this  location  which  brings  the  cavity  close  to  the  diaphragm.  The 
whole  lower  lobe  shows  advanced  caseous  pneumonia,  and  also  the  greater 
part  of  the  upper  lobe,  especially  posteriorly.  The  air-contents  is  absent, 
except  along  the  anterior  border,  and  at  the  apex.  On  both  sides  the 
bronchial  glands  are  very  much  enlarged  and  caseous.  Miliary  tubercles  in 
the  liver,  spleen,  and  intestines.  The  mesenteric  glands  are  caseous.  The 
microscopical  examination  of  a  section  of  lung  close  to  the  cavity  wall  shows 
diffuse  cellular  infiltration  of  tuberculo-pneumonic  type.  The  type  of  cells 
present  are  lymphoc}i:es  with  a  very  few  polymorphonuclear  cells.  There 
is  congestion  of  the  capillaries  and  giant-cell  formation.  The  tissues  in  the 
immediate  vicinity  of  the  cavity  wall  show  numerous  large  areas  of  typical 
caseation,  but  there  is  very  little  fibrous  tissue  formation.  The  large  bron- 
chial tubes  in  the  neighborhood  show  marked  bronchitis;  the  cellular  exu- 
date consisting  of  polymorphonuclear  cells  and  lymphocytes.  The  walls  of 
the  bronchi  show  the  infiltrating  process. 

Case  IV. — Robert  W.,  eleven  months  old,  colored,  was  admitted  to  the 
hospital  November  28,  1905.  The  family  history  was  negative;  the  mother 
and  father  living  and  well.  There  was  only  one  other  child  and  it  was  well. 
There  was  no  history  of  tuberculosis  in  the  family.  The  baby's  birth  was 
normal,  and  up  to  the  time  of  admission  it  had  been  fed  exclusively  on  breast- 
milk.  It  had  always  been  well,  with  the  exception  of  an  attack  of  gastro- 
enteritis when  six  months  old.  For  several  months  before  coming  to  the 
hospital  infant  had  had  a  cough,  which  in  the  last  two  weeks  had  become 
much  more  severe.  On  admission  the  infant  presented  the  physical  signs  of 
a  bronchopneumonia.  Two  days  later  it  became  much  worse,  cough  very 
severe,  especially  at  night.  It  did  not  take  its  feedings  well,  and  the 
bowels  became  loose.  It  began  to  vomit,  and  on  one  occasion  the  vomited 
material  was  streaked  with  blood.  The  infant  died  twenty -two  days  after 
admission. 

Pathological  diagnosis:  Caseous  bronchopneumonia.    General  tubercu- 


PULMONARY  CAVITIES  IN  INFANTS. — WHITE  AND  CARPENTER.  443 

losis.  Tuberculosis  of  liver,  spleen,  mesenteric  and  bronchial  glands.  Tu- 
berculous enteritis  and  peritonitis.     Chronic  fibrinous  pleurisy. 

The  left  lung  weighs  62  grams.  It  is  slightly  congested,  and  shows  a 
sUght  amount  of  edema.  This  lung  contains  a  few  scattered,  gray,  miUary 
tubercles.  The  bronchial  glands  are  slightly  enlarged.  The  right  lung 
weighs  205  grams.  The  whole  lung  is  consolidated;  it  is  firm  in  consistency 
and  grayish-yellow  in  color.  The  surface  section  is  smooth,  dry,  and  dull. 
There  is  a  cavity  at  the  upper  part  of  the  middle  lobe,  external  to  the  mid- 
clavicular line.  The  cavity  measures  2  by  1  by  3^  cm.  in  size.  The  cavity 
extends  upward  into  the  upper  lobe.  The  walls  of  the  cavity  are  dark  in 
color  and  covered  with  granulations.  In  the  upper  lobe  there  is  an  excess 
of  fibrous  tissue.  Over  the  right  lung  there  is  a  chronic  adhesive  pleurisy. 
There  is  tuberculosis  of  the  intestines,  peritoneum,  spleen,  liver,  appendix, 
and  mesenteric  glands.  A  microscopical  examination  of  a  section  from  the 
wall  of  the  cavity  shows  fibrous  tissue,  and  a  cellular  exudate  consisting  of 
polymorphonuclear  cells  and  small  lymphocytes.  The  tissue  in  close  prox- 
imity to  the  cavity  wall  consists  of  an  overgrowth  of  fibrous  tissue,  which 
extends  into  the  alveolar  walls.  Embedded  in  this  fibrous  tissue  there  are 
collections  of  typical  tubercles;  they  are  for  the  most  part  small  and  show  a 
small  amount  of  caseation.  Giant-ceUs  are  very  prominent.  The  surround- 
ing lung  tissue  shows  the  capillaries  congested.  Wide-spread  caseation  of 
the  caseo-pneumonic  type  is  not  present.  The  process  is  a  chronic  fibro- 
caseous  tuberculosis,  with  the  presence  of  many  giant-cells. 

Case  V. — Lilhan  P.,  one  year  old,  colored,  was  admitted  to  the  hospital 
May  27,  1907.  The  parents  were  both  living  and  well.  There  had  been  no 
other  children.  Patient's  birth  was  normal,  and  until  the  time  of  her  ad- 
mission she  had  been  breast-fed.  She  had  never  had  pertussis,  measles, 
or  any  contagious  disease.  Baby  had  had  fever  for  one  month  before  coming 
to  the  hospital.  She  had  been  vomiting  sour  milk  immediately  after  feed- 
ing several  times  a  day.  The  bowels  were  constipated.  For  three  days 
before  admission  she  had  a  number  of  general  convulsions,  lasting  from  five 
to  ten  minutes.  Examination  revealed  harsh  breathing  all  over  lungs  with 
many  large  moist  rales.  She  had  slight  rigidity  of  neck  muscles  and  a 
positive  Kernig's  sign.  By  lumbar  puncture  45  c.c.  of  slightly  cloudy 
fluid  was  withdrawn,  in  which  tubercle  bacilli  were  found.  Child  died 
forty-eight  hours  following  admission,  after  having  had  a  number  of  convul- 
sions. 

Pathological  diagnosis:  Caseous  bronchopneumonia.  Tuberculous  en- 
teritis.    Tuberculosis  of  liver  and  spleen.     Tuberculous  meningitis. 

The  left  lung  is  10  by  8  by  3 ^  cm.  and  weighs  80  grams.  The  pleura  is 
normal.  The  surface  section  of  the  lung  shows  numerous  small,  gray, 
translucent  tubercles,  without  bronchopneumonia.  The  tubercles  are  iso- 
lated. There  is  slight  hypostatic  congestion  in  the  dependent  parts.  The 
lung  is  crepitant  and  exudes  bloody  fluid  on  pressure.  Bronchi  and  pulmon- 
ary vessels  are  normal.  The  bronchial  lymph-glands  are  greatly  enlarged. 
The  right  pleura  is  congested  and  thickened.  There  are  firm  adhesions  from 
the  right  upper  lobe  in  the  anterior  axillary  line,  and  from  the  middle  lobe 
to  the  fourth  rib.  There  are  adhesions  posteriorly  over  the  upper  lobe. 
The  right  lung  measures  13  by  9^  by  3  cm.  and  weighs  95  grams.    Generally 


444  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

this  lung  is  the  same  as  the  left,  with  the  exception  of  the  upper  lobe.  The 
upper  lobe  contains  a  cavity  H  by  H  by  2  cm.  situated  1  cm.  from  the  apex; 
and  another  cavity  below  this  at  the  base  of  the  lobe  measuring  2h  by  2  by 
1  cm.  Surrounding  these  cavities  the  lung  tissue  in  this  lobe  is  consolidated 
by  a  caseous  pneumonia.  On  pressure  a  muco-pus  exudes.  The  liver  shows 
fatty  change  and  there  are  translucent  gray  tubercles  distributed  throughout. 
The  spleen  contains  a  few  gray  tubercles.  The  small  and  large  intestines 
show  numerous  tubercular  ulcers,  especially  in  the  lower  part  of  the  ileum. 
The  mesenteric  glands  are  greatly  enlarged  and  some  are  caseous. 

Case  VI. — ^Braxton  R.,  five  months  old,  colored,  was  admitted  to  the 
hospital  February  6,  1907.  His  father,  mother,  and  two  sisters  are  living 
and  well.  Infant's  birth  was  normal,  and  it  had  never  been  sick  until  six 
weeks  before  admission.  During  this  time  he  had  a  severe  cough.  IMother 
states  that  a  dark  colored  discharge  comes  from  nose  during  coughing  at- 
tacks. The  physical  examination  revealed  an  emaciated  colored  infant, 
whose  lungs  showed  numerous  moist  rales,  both  anteriorly  and  posteriorly. 
A  smear  made  from  throat,  in  order  to  obtain  some  expectoration,  showed  no 
tubercle  bacilh.  Heart  and  abdomen  were  negative.  There  was  a  small 
amount  of  blood  in  the  bowel  movements.  Infant  died  eleven  days  after 
admission. 

Pathological  diagnosis:  Caseous  bronchopneumonic  tuberculosis.  Gen- 
eral miliary  tuberculosis.  Tuberculous  pleurisy  and  peritonitis.  Tubercu- 
losis of  liver,  spleen,  kidneys,  and  intestines.  Fatty  heart  and  kidneys. 
The  pleura  on  the  left  side  is  normal,  but  on  the  right  side  there  are  tubercu- 
lous adhesions.  The  left  lung  measured  9  by  5  by  3  cm.  and  weighs  45 
grams.  The  air-contents  is  greatly  decreased  and  there  are  a  number  of 
large  yellow  tubercles  scattered  throughout  the  lung.  The  right  lung  is 
10  by  6  by  3.5  cm.  and  weighs  85  grams.  This  lung  shows  extensive  pneu- 
monia with  many  yellow  tubercles,  and  tuberculous  infiltration  around  the 
small  bronchi.  Crepitation  is  absent,  the  lung  is  firm  in  consistency,  and 
the  amount  of  blood  is  increased.  At  the  right  apex  posteriorly  the  pulmon- 
ary tissue  is  broken  down,  leaving  a  tuberculous  cavity  2  by  1  cm.  On  the 
parietal  peritoneum  are  seen  a  number  of  discrete  yellowish  tubercles  3  mm. 
in  diameter,  having  the  appearance  of  bovine  tuberculosis.  There  are  mili- 
ary tubercles  in  the  liver,  spleen,  kidneys,  and  intestines. 

In  the  six  cases  we  report  of  cavity  formation,  all  occurred  in  negro 
infants  between  the  ages  of  five  and  fifteen  months  old.  Our  experience 
bears  out  the  well-known  fact  that  the  colored  race  is  especially  susceptible 
to  tuberculosis,  and  the  cases  autopsied  usually  showed  wide-spread  lesions 
of  an  advanced  type.  Miliary  tubercles  were  present  in  the  lungs  especially, 
and  to  a  less  extent  in  other  organs.  These  lesions  were  usually  small,  in 
all  likelihood  an  evidence  of  a  terminal  infection,  and  were  secondary  to  the 
larger  lesions  either  of  the  lungs  or  lymphatic  nodes.  The  bronchial  glands 
were  tuberculous  in  all  these  cases.  The  pleura  in  our  cases  showed  wide- 
spread adhesions  or  distinct  miliary  tubercles. 

No  data  were  obtainable,  either  in  the  family  or  personal  history  of  the 


PULMONARY  CAVITIES  IN  INFANTS. — WHITE  AND  CARPENTER.  445 

cases,  which  would  indicate  the  source  of  infection.  In  only  one  case  had 
there  been  any  disease  prior  to  the  fatal  illness.  (The  exception  was  an  at- 
tack of  gastro-enteritis  in  Case  IV.)  Three  of  our  cases  had  been  fed  ex- 
clusively on  the  breast  until  admitted  to  the  hospital. 

The  cavity  formation  in  the  lungs  was  with  one  exception  of  short  dura- 
tion, and  occurred  in  the  larger  caseous  areas  of  the  lungs,  and  was  not  sur- 
rounded by  fibrous  tissue  so  commonly  found  in  older  children.  In  one  case 
only  was  the  process  of  longer  duration  and  showed  the  formation  of  fibrous 
tissue  around  the  borders  of  the  cavity. 

In  conclusion :  Cavity  formation  does  not  occur  with  the  same  frequency 
in  infants  as  in  older  cliildren.  In  our  own  autopsies  16  per  cent,  of  the 
infants  djdng  from  tuberculosis  showed  ca\dty  formation — a  far  lower  per- 
centage than  reported  by  other  observers.  The  type  of  lesion  observed  by 
us  is  not  of  the  variety  which  lasts  long  enough  to  produce  cavity  formation. 
The  infants  usually  succumb  to  the  wide-spread  process  before  the  larger 
lesions  have  time  to  soften  and  their  contents  to  be  thrown  off. 

In  our  cases  tuberculous  cavities  in  infants  occurred  most  often  at  the 
root  of  the  lungs  in  the  middle  and  lower  lobes. 


SECTION  IV. 


Tuberculosis  in  Children — Etiology,  Prevention, 
and  Treatment  {Continued), 


SECOND  DAY.    AFTERNOON  SESSION. 

Tuesday,  September  29,  1908. 

ABDOMINAL   TUBERCULOSIS.     TUBERCULOSIS    OF  THE   PERICAR- 
DIUM.    INTERMITTENT  ALBUMINURIA. 


The  President,  Dr.  Jacobi,  called  the  Section  to  order  at  three  o'clock. 


THE  RELATIVE  FREQUENCY  OF  ABDOMINAL  TUBER- 
CULOSIS IN  CHILDREN  IN  GREAT  BRITAIN 
AND  THE  UNITED  STATES. 

By  David  Bovaird,  Jr!,  M.D., 

New  York. 


In  1901,  in  the  course  of  an  investigation  regarding  the  frequency  of 
primary  intestinal  tuberculosis  in  children,  there  was  developed  a  remarkable 
discrepancy  between  the  data  derived  from  the  hospitals  of  Great  Britain 
and  those  of  New  York.  Thus  the  British  statistics  gave  18  per  cent,  of 
primary  intestinal  infections  against  1  per  cent,  for  New  York.  It  seemed 
hardly  possible  that  there  could  be  so  great  a  discrepancy,  and  there  was  a 
natural  tendency  to  seek  the  explanation  in  differences  in  methods  of  ex- 
amination, rather  than  to  accept  the  figures  as  true.  During  the  last  few 
years,  observations  have  been  made  which  show  an  equal  discrepancy  in 
the  data  regarding  the  frequency  of  abdominal  tuberculosis,  as  determined 
by  clinical  observations  in  these  two  countries;  and  as  it  will,  I  believe, 
be  granted  that  where  primary  intestinal  tuberculosis  is  frequent,  there  ab- 
dominal tuberculosis  (that  is,  tuberculosis  of  the  intestines,  mesenteric 
glands,  lymph-nodes,  and  peritoneum)  ought  to  be  frequent,  or,  conversely, 
abdominal  tuberculosis  should  be  rare  when  primary  intestinal  infections  are 

446 


FREQUENCY  OF  ABDOMINAL  TUBERCULOSIS. — BOVAIRD. 


447 


uncommon,  it  has  seemed  that  the  subject  is  important.     If  it  can  be  shown 

that  abdominal  tuberculosis  is  much  more  frequent  in  Great  Britain  than  in 

the  United  States,  we  shall  have  corroborative  evidence  of  the  remarkable 

data  regarding  the  frequency  of  primary  intestinal  tuberculosis,  and  shall  be, 

therefore,  more  ready  to  accept  them  as  correct;  and  if  correct,  these  data 

present  a  problem  in  the  study  of  tuberculosis  in  children  the  solution  of 

wliich  must  have  an  important  bearing  on  the  prevention  of  tuberculosis 

in  the  young. 

TABLE  I. 

SHOWING    RATIOS    OF   ABDOMINAL  TUBERCLT.OSIS  AND  TUBERCULAR 
MENINGITIS  TO  TOTAL  ADMISSIONS  IN  3  BRITISH  HOSPITALS. 


Royal  Hospital  for  Sick  Children. 

Edinburgh. 

1897 

1898 

1899 

1900 

1901 

1902 

1903 

1904 

1905 

1906 

Aver- 
age 

Number  of  pa- 
tients admitted . 

Percentage  of  ab- 
dominal tuber- 
culosis   

Percentage  of  tu- 
bercular menin- 
gitis   

1,154 
3.63 
3.29 

1,219 
3.75 

2.87 

1,361 

2.57 
2.42 

1,398 
4.36 
2.21 

1,533 
2.73 
2.02 

1,597 
3.63 
1.63 

1,504 
4.98 
2.12 

1,596 
3.82 
1.12 

1,844 
3.14 
1.57 

2,114 
3.20 
1.27 

1,532 
3.57 
2.05 

Hospital  for  Sick  Children.     Great  Ormond  St.,  London. 


1897 

1898 

1899 

1900 

1901 

1902 

1903 

1904 

1905 

1,946 

2,067 

1,962 

1,690 

2,111 

2,236 

2,403 

2,537 

2,876 

0.66 

1.11 

1.32 

1.71 

1.46 

1.61 

2.03 

2.24 

2.60 

1.49 

0.72 

1.52 

1.88 

1.27 

1.11 

1.16 

1.65 

1.53 

1906 


Aver- 
age 


Number  of  pa- 
tients admitted . 

Percentage  of  ab- 
dominal tuber- 
culosis   

Percentage  of  tu- 
bercular menin- 
gitis   


3,068'  2,289 


1.98 


1.85 


1.67 


1.42 


Royal  Hospital  for  Sick  Children.     Glasgow. 


Number  of  pa- 
tients admitted 

Percentage  of  ab 
dominal  tuber 
culosis 

Percentage  of  tu- 
bercular menin- 
gitis   


1897 

1898 

1899 

1900 

1901 

1902 

1903 

1904 

1905 

1906 

691 

744 

741 

714 

738 

854 

996 

941 

1,125 

1,075 

4.05 

4.30 

3.91 

3.92 

5.28 

4.58 

4.32 

5.10 

5.24 

4.46 

1.49 

0.72 

1.52 

1.88 

1.27 

1.11 

1.16 

1.65 

1.53 

1.85 

Aver- 
age 


882 
4.51 
1.42 


448 


SIXTH  INTERNATIONAL  CONGRESS   ON  TUBERCULOSIS. 


TABLE  II. 

SHOWING    RATIOS  OF  ABDOMINAL  TUBERCULOSIS   AND  TUBERCULAR 
MENINGITIS  TO  TOTAL  ADMISSIONS  IN  3  AMERICAN  HOSPITALS  (U.  S.). 

Babies'  Hospital.     New  York. 


1900 

1901 

1902 

1903 

1904 

1905 

1906 

1907 

Aver- 
age 

Number  of  patients  admitted .  . 
Percentage  of  abdominal  tuber- 
culosis   

395 

0. 

0.8 

475 
0.4 
1.2 

342 

0. 

0.9 

610 

0. 

0.8 

946 

0. 

0.9 

1,036 
0.1 
1.9 

1,031 
0.1 
3.0 

979 
0.2 
2.0 

728 
0  1 

Percentage  of  tubercular  men- 
ingitis   

1.4 

Children's  Hospital.     Boston. 


Number  of  patients  admitted .  . 

Percentage  of  abdominal  tu- 
berculosis   

Percentage  of  tubercular  men- 
ingitis   


1893 

1894 

1895 

1896 

1897 

1898 

581 

675 

758 

765 

910 

927 

0.4 

0.0 

0.4 

0.4 

0.4 

1.0 

1.0 

0.3 

1.0 

2.5 

1.5 

1.4 

Aver- 
age 

768 
0.4 
1.3 


Post-Graduate  Hospital.     New  York. 


Number  of  patients  admitted.  . 

Percentage  of  abdominal  tu- 
berculosis   

Percentage  of  tubercular  men- 
ingitis   


1899 

1900 

1902 

1903 

1904 

1905 

1906 

1,035 

979 

953 

934 

1,121 

1,111 

1,059 

0.5 

0.2 

0.6 

0.2 

0.6 

0.9 

0.6 

1.5 

0.0 

0.5 

1.1 

0.0 

0.4 

0.4 

Aver- 
age 


1,028 
0.51 
0.56 


My  interest  in  the  relative  frequency  of  abdominal  tuberculosis  was 
aroused  by  a  visit  to  the  Royal  Hospital  for  Sick  Cliildren,  Edinburgh,  in 
1904.  Under  the  guidance  of  Dr.  John  Thomson,  I  was  showTi,  in  a  single 
morning,  more  cases  of  unquestionable  abdominal  tuberculosis  in  children 
than  had  come  under  my  observation  in  ten  years'  work  in  the  dispensaries 
and  hospitals  of  New  York  city.  Dr.  Thomson  was  impressed  by  tliis  fact, 
and  published  a  paper  on  the  subject  in  the  "British  Journal  of  Tuberculosis," 
July,  1907,  giving  data  from  the  hospitals  of  Edinburgh,  Glasgow,  and 
London,  and  contrasting  these  with  such  American  statistics  as  he  could 
obtain.  I  desire  merely  to  present  Dr.  Thomson's  data  regarding  the  hos- 
pitals of  Great  Britain,  and  to  compare  them  with  the  returns  from  American 
hospitals  not  accessible  to  him. 


FREQUENCY  OF  ABDOMINAL  TUBERCULOSIS. — BOVAlRD. 


449 


You  wiW  observe  that,  in  these  data,  the  total  number  of  cliildren  treated 
yearly  in  each  institution,  and  the  number  of  cases  of  abdominal  tuber- 
culosis and  of  tubercular  meningitis,  are  given.  The  figures  for  tubercular 
meningitis  are  used  as  an  index  of  the  relative  frequency  of  tuberculosis  in 
all  forms.  As  is  well  known,  the  meningeal  disease  may  be  the  terminal 
event  in  any  form  of  tuberculosis,  and  its  incidence  will  probably  reflect 
quite  accurately  the  frequency  of  tuberculosis  in  any  community.  Com- 
parison of  the  ratios  of  abdominal  tuberculosis  and  tubercular  meningitis 
will,  therefore,  show  us  when,  and  to  what  extent,  the  abdominal  type  of 
disease  prevails. 

TABLE  III. 
FREQUENCY  OF  ABDOMINAL  TUBERCULOSIS  IN  GREAT  BRITAIN. 


Hospital. 

Total  Number 
Treated. 

Abdominal 
Tuberculosis. 

Tubercular 
Meningitis. 

Great  Ormond  Street 

22,890 
15,320 

8,820 

382 
547 
398 

329 

Edinburgh  Children's 

314 

Glasgow  Children's 

126 

Totals 

47,030 

1327 

769 

Percentage  of  abdominal  tuberculosis  =  3. 
Percentage  of  tubercular  meningitis  =  1.6 
Abdominal  Tuberculosis  :  Tubercular  Meningitis : :  2 


TABLE  IV. 
FREQUENCY  OF  ABDOMINAL  TUBERCULOSIS   IN   THE  UNITED   STATES. 


Hospital. 


Post-Graduate 

Babies',  1888-1901  

Babies',  1902-1907 

New  York  Infant  Asylum,  1894- 

1900 

Children's,  Buffalo,  1892-1900.  .  .  . 

Children's,  Boston 

Seaside,  1900-1907 

New  York  Foundling 

Presbyterian 

Mount  Sinai 


Years. 


Totals . 


7 

13 

5 


Total  Num- 
ber Treated. 


7,222 
4,554 
4,944 

4,098 
1,151 
4,616 
7,231 
2,875 
610 
2,266 


39,567 


Abdominal 
Tuberculosis. 


36 
4 
4 

1 
0 
21 
5 
2 


82 


Tubercular 

Meningitis. 


39 
31 

86 

5 
3 
43 
6 
26 
26 
80 


345 


Percentage  of  abdominal  tuberculosis  =  0.21 
Percentage  of  tubercular  meningitis  =  0.9 
Abdominal  Tuberculosis  :  Tubercular  Meningitis  : 
vr»L.  a — 15 


0.21  :0.9,  or::  1:4. 


450  SIXTH   INTERNATIONAL   CONGRESS    ON    TUBERCULOSIS. 

The  most  striking  feature  of  these  tables  is  the  constancy  of  the  ratios 
for  both  types  of  tuberculosis  in  each  of  the  hospitals  represented.  At- 
tention may  also  be  called  to  the  fact  that  there  is  three  times  as  much  ab- 
dominal tuberculosis  in  Glasgow  as  in  London,  if  the  hospitals  quoted  may 
be  regarded  as  t}^ical  of  conditions  prevailing  in  their  respective  com- 
munities. 

If,  now,  we  strike  an  average  for  the  three  cities,  we  find  that  these  tables 
give  9.75  per  cent,  of  cases  of  abdominal  tuberculosis  to  4.89  per  cent,  of 
cases  of  meningeal  tuberculosis,  or  practically  2  to  1,  as  representing  the 
conditions  prevailing  in  Great  Britain.  Alongside  these  figures,  I  place 
similar  data  from  a  number  of  hospitals  in  the  United  States.  It  is  at 
once  evident  that  the  figures  differ  markedly  for  the  several  hospitals,  and 
also  in  the  same  hospitals  from  year  to  year.  Desiring  to  eliminate  what 
must  be  regarded  as  the  play  of  chance  in  the  tables,  I  have  dropped  the 
classification  of  returns  by  years  and  massed  the  statistics  from  all  the  hos- 
pitals available  in  Tables  III  and  IV. 

There  has  been  no  selection  of  data.  The  figures  for  every  hospital  whose 
returns  were  accessible  are  here  given.  The  contrasts  in  several  instances 
are  striking,  but  I  shall  not  turn  aside  to  consider  them.  The  figures  make 
it  clear  that,  on  the  whole,  tuberculosis  is  much  less  frequent  among  children 
in  the  United  States  than  in  Great  Britain.  They  also  show  that  we  have, 
on  the  average,  four  cases  of  meningeal  tuberculosis  for  one  of  abdominal 
tuberculosis.  Comparing  this  result  with  that  already  obtained  for  Great 
Britain,  we  may  safely  say  that,  taking  into  consideration  the  frequency  of 
the  abdominal  localization  in  cases  clinically  tuberculous,  we  find  that  such 
localization  is  eight  times  more  frequent  in  Great  Britain  than  in  the  United 
States.  Or,  comparing  the  figures  for  the  hospitals  individually,  the  number 
of  cases  of  abdominal  tuberculosis  is  found  to  be  four  times  gi-eater  in  Great 
Ormond  Street  than  in  the  United  States;  in  the  Edinl^urgh  Children's 
Hospital  it  is  about  eight  times,  and  in  the  Glasgow  Children's  Hospital 
about  twelve  times,  greater. 

If,  however,  we  take  the  frequency  of  the  two  types  of  tuberculosis  in 
the  total  number  of  sick  children  treated,  we  see  that,  on  the  average,  ab- 
dominal tuberculosis  is  fifteen  times  as  frequent  in  Great  Britain  as  in  this 
country,  the  figures  being  3.25  per  cent,  of  the  total  number  treated  in  Great 
Britain  and  0.22  per  cent,  in  the  United  States. 

These  figures  surely  demonstrate  beyond  doubt  that  abdominal  tubercu- 
losis is  many  times  more  frequent  among  children  in  Great  Britain  than 
among  those  in  the  United  States. 

As  was  said  at  the  beginning  of  the  paper,  this  fact  is  of  great  importance 
when  placed  in  juxtaposition  to  the  data  derived  from  post-mortem  exam- 
inations as  to  the  frequency  of  primary  intestinal  tuberculosis. 


FREQUENCY  OF  ABDOMINAL  TUBERCULOSIS. — BOVAIRD, 


451 


TABLE   V. 

FREQUENCY  OF  PRIMARY  INTESTINAL  TUBERCULOSIS  AS  DETERMINED 
BY  POST-MORTEM  EXAMINATIONS. 

In  Great  Britain 

Total  Number  of 
Examinations. 

Cases  of  Definite  Primary 
Intestinal  Tuberculosis. 

Carr 

120 
127 
77 
269 
155 
413 

20 

Woodhead 

Guthrie 

14 
19 

Still 

63 

Ashby 

20 

Shennan 

100 

Totals 

1161 

236  =  20% 

In  the  United  States. 

Total  Number  of 
Examinations. 

Cases  of  Definite  Primary 
Intestinal  Tuberculosis. 

Northriip 

125 
119 
125 
115 
136 

3 

Holt 

0 

Bovaird 

2 

Hand 

10 

Foundling  Hospital  (unpublished) 

6 

Totals 

620 

21  =  3.5% 

We  may  add  that  some  writers  (Sydney  Smith)  claim  that  these  figures 
are  low,  and  that  30  per  cent,  of  all  cases  of  tuberculosis  in  cliildren  in  Great 
Britain  show  a  primary  intestinal  lesion.  Here  we  have  the  same  discrep- 
ancy that  we  found  in  the  clinical  data,  and  it  seems  to  me  that,  taken  to- 
gether, these  figures  confirm  one  another  and  establish,  as  thoroughly  as 
need  be,  the  fact  that  intestinal  infection,  in  tuberculosis  of  children,  is  many 
times  more  frequent  in  Great  Britain  than  it  is  here. 

It  may  also  be  said  that  it  is  probable  that  a  careful  investigation  would 
reveal  a  similar  contrast  between  Great  Britain  and  Germany  and  France, 
for  the  data  which  I  was  able  to  gather  six  years  ago  indicated  clearly  that  a 
general  harmony  existed  between  the  findings  of  German  and  French  ob- 
servers and  our  own,  the  data  from  Great  Britain  being  at  variance  with 
all  the  others.  This  difference  as  to  the  fundamental  facts  regarding  tuber- 
culosis in  children  particularly,  I  believe  explains  the  apparently  irreconcil- 
able views  held  by  the  writers  of  different  nationalities  as  to  the  freciuency 
of  bovine  infections;  for,  whatever  the  interpretation  of  the  localization  of 
the  lesions  with  relation  to  the  path  of  infection,  there  is  general  agreement 
that  if  infection  takes  place  from  milk,  it  will  most  probably  show  itself  in 
tuberculous  lesions  of  the  intestines,  mesenteric  nodes.,  and  possibly  peri- 


452  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

toneum — in  other  words,  abdominal  tuberculosis.  This  fact  has  been  amply 
proved,  for  all  recent  investigations  of  the  type  of  tubercle  bacilli  to  be  found 
in  human  lesions  show  that  the  bovine  type  is  frequently  (70  per  cent.) 
found  in  cases  of  abdominal  or  cervical  gland  tuberculosis  in  children,  and 
rarely  in  other  cases. 

It  is,  of  course,  true  that  the  investigations  of  cases  for  types  of  bacilli 
have  not  been  numerous  enough  to  be  decisive,  but  the  evidence  available 
justifies  the  statement  that  when  abdominal  tuberculosis  is  common,  then 
bovine  infection  will  be  found  frequent,  and  not  under  other  conditions. 
The  application  of  this  proposition  to  the  data  I  have  given  is  obvious. 


Relative  Haufigkeit  von  Bauchtuberkulose  in  Grossbritannien  und  den 
Vereinigten  Staaten. — (Bovaird.) 

1.  Im  Laufe  einer  Untersuchung  der  Daten  beziiglich  Tuberkulose  bei 
Kindern  in  verschiedenen  Landern  zeigte  der  Autor  im  Jahre  1901  einen 
bemerkenswerten  Widerspruch  zwischen  den  Zahlen  fiir  primare  Darm- 
tuberkulose  in  Grossbritannien  und  denjenigen  der  Vereinigten  Staaten. 

2.  Dass  dieser  Unterschied  wirklich  vorhanden  ist  und  nicht  von  der 
verschiedenen  Interpretation  dessen  abhangt,  was  in  khnischen  Daten 
beziiglich  der  Bauchtuberkulose  bei  Kindern  in  diesen  Landern  gefunden 
wurde. 

3.  Das  Wort  "Bauchtuberkulose,"  wie  es  hier  gebraucht  wird,  ist  so 
gemeint,  um  darunter  Tuberkulose  des  Darmes,  der  Knoten  im  Mesenterium 
und  des  Bauchfells  zu  verstehen. 

4.  Daten  aus  den  Hospitalern  von  Edinburgh,  Glasgow  und  London, 
verglichen  mit  jenen  aus  den  Hospitalern  von  New  York  und  Boston,  zeigen: 

a.  Dass  Tuberkulose  (alle  Formen)  in  den  Vereinigten  Staaten  viel 
weniger  haufig  ist  als  in  Grossbritannien. 

b.  Dass,  wenn  man  diese  Tatsache  in  Betracht  zieht,  noch  ein  wahr- 
nehmbarer  Contrast  in  den  die  Bauchtuberkulose  betreffenden  Daten  vor- 
handen ist,  welcher  zeigt,  dass  sie  viel  hiiufiger  in  Grossbritannien  ist,  als  in 
den  Vereinigten  Staaten. 

5.  Dass  der  Contrast  geniigend  gross  ist,  um  zu  zeigen,  dass  manche 
besondere  Bedingungen  vorhanden  sein  miissen,  die  die  ungewohnUche 
Haufigkeit  der  Bauchtuberkulose  in  Grossbritannien  bestimmen. 

6.  Es  mag  einigermassen  angenommen  werden,  dass  Bauchtuberkulose 
im  allgemeinen  die  Haufigkeit  von  primaren  tuberkulosen  Erkrankungen 
des  Darmtraktes  und  der  Nahrungswege  wiedergibt. 

7.  Zu  gleicher  Zeit  taucht  die  Vermutung  auf,  dass  das  Uberwiegen  der 
Bauchtuberkulose  in  Grossbritannien  von  einem  correspondierenden  Uber- 
wiegen der  Ptindertuberkulose  abhangig  sei. 


FREQUENCY  OF  ABDOMINAL  TUBERCULOSIS. — BOVAIRD.        453 

8.  Keine  solche  Daten  zeigen  sich  bei  Betrachtung  der  Rindertuber- 
kulose. 

9.  Weitere  Studien  beziiglich  der  Bauchtuberkulose  zeigen,  dass  diese 
Affection  zum  mindesten  nicht  im  Kindesalter  (1  bis  2  Jahren)  vorlvommt, 
wenn  Kuhmilch  zumeist  als  Nahrung  verwendet  wird,  sondern  den  spateren 
Lebensaltern  angehort. 


La  frecuencia  relativa  de  la  Tuberculosis  Abdominal  en  la  Gran  Bretana 
y  los  Estados  Unidos. — (Bovaird.) 

1.  En  el  curso  de  una  investigacion  con  relacion  a  la  tuberculosis  en 
los  ninos  en  los  diferentes  paises,  en  1901,  observe  el  autor  la  existencia  de 
una  notable  discrepancia  en  los  resultados  de  la  tuberculosis  abdominal  en 
la  Gran  Bretana  y  los  Estados  Unidos. 

2.  Que  la  diferencia  es  real  y  no  debida  a  la  diferencia  en  la  iiiterpre- 
tacion  de  los  resultados,  es  bien  demostrada  por  medio  de  los  datos  clinicos 
con  relacion  a  la  tuberculosis  abdominal  en  estos  paises. 

3.  El  termino  tuberculosis  abdominal,  aqui  usado,  incluye  la  tubercu- 
losis de  los  intestinos,  glandulas  mesentericas  y  peritoneo. 

4.  Demostracion  de  los  datos  obtenidos  en  el  hospital  de  Edimburgo, 
Glasgow  y  Londres  comparados  con  los  datos  obtenidos  en  los  hospitales  de 
New  York  y  Boston. 

a.  La  tuberculosis  (en  todos  sus  formas)  es  menos  frecuente  en  los 
Estados  Unidos  que  en  la  Gran  Bretana. 

b.  Que  tomando  en  concideracion  estos  datos,  aun  todavia  existe  un 
marcado  contraste  con  relacion  a  la  tuberculosis  abdominal  la  cual  es  mas 
frecuente  en  la  Gran  Bretaila  que  en  los  Estados  Unidos. 

5.  Que  el  contraste  es  suficientemente  grande  para  demostrar  que 
ciertas  condiciones  especiales  existen  las  cuales  determinan  la  frecuencia  de 
la  tuberculosis  abdominal  en  la  Gran  Bretana. 

6.  La  tuberculosis  abdominal,  puede  muy  bien  presurairse,  representa 
por  lo  general  la  infeccion  primitiva  del  intestino  6  del  aparato  digestivo  en 
general. 

7.  La  suggestion  k  primera  vista  es,  que  la  frecuencia  de  la  tuberculosis 
abdominal  en  la  Gran  Bretana  es  debida  a  una  frecuencia  correspondiente 
de  la  tuberculosis  en  el  ganado. 

8.  Los  datos  no  demuestran  una  tal  preponderancia  en  la  tuberculosis 
bovina. 

9.  Estudio  de  estos  resultados  demuestran  que  la  tuberculosis  abdominal, 
en  este  pais  a  lo  menos,  no  es  comun  antes  de  la  edad  de  2  aiios  cuando  la 
leche  es  el  aliraento  principal  sino  que  es  mas  frecuente  en  la  edad  mas 
avanzada. 


LA  PERITONITE  TUBERCULEUSE  DU  NOURRISSON. 

Par  M.  E.  Weill, 

Professeur  de  clinique  infantile  h  I'Universit^ 
de  Lyon. 

ET  M.  Pehu, 

M^decin  des  hopitaux 
de  Lyon. 


Parmi  les  manifestations  diverses  que  peut  affecter  la  tuberculose  dans 
le  premier  age,  on  peut  compter  la  localisation  du  bacille  sur  la  sereuse  peri- 
toneale.  Mais,  tandis  que  de  nombreux  et  importants  travaux  ont  bien  fix6 
la  physionomie  si  particuliere  de  la  tuberculose  chez  le  nourrisson,  ses  formes 
cliniques,  sa  localisation  sur  les  visceres,  il  n'en  est  pas  de  meme  de  la  tuber- 
culose du  peritoine  a  cet  age  de  la  vie :  son  histoire  complete  n'a  pas  6te  tracee 
encore. 

A  I'occasion  de  deux  cas  personnels  il  nous  a  semble  utile  de  reunir  toutes 
les  observations  publiees  sur  ce  sujet,  et  d'ecrire,  sur  la  peritonite  tubercu- 
leuse  du  nourrisson,  une  etude  d'ensemble  permettant  de  fixer  avec  precision 
les  details  nosographiques  qui  la  concernent. 

I.  L'histoire  de  la  peritonite  tuberculeuse  chez  le  nourrisson  est  fort 
courte:  il  n'existe,  du  moins  a  notre  connaissance,  aucune  monographic 
d'ensemble  sur  ce  sujet.  Elle  est  ^tudiee  incidemment  a  propos  des  observa- 
tions sur  la  tuberculose  du  premier  age  publiees  surtout  depuis  que  les  tra- 
vaux de  Landouzy  et  Queyrat  ont  montre  que  I'infection  par  le  bacille 
de  Koch  etait  beaucoup  moins  rare  chez  le  nourrisson  qu'on  ne  I'enseignait 
jusqu'alors  (1883). 

II  est  superflu  de  rappeler  les  anciennes  conceptions  qui  r^gnerent,  dans 
les  idees  medicales,  a  la  fin  du  xviii''  siecle  et  au  commencement  du  xix^ 
lorsque  Baumes  (1787)  proclama  qu'il  existe  une  maladie  bien  definie  comme 
sous  le  nom  de  "  carreau  ",  qui  resumait  a  elle  seule  la  tuberculose  abdominale 
chez  le  nourrisson,  la  tuberculose  ent^ro-peritoneale  disait  on  a  I'heure 
actuelle.  Les  vues  de  Baumes  n'eurent  qu'une  vogue  ^phemere  puisque, 
des  1830,  Guersant  les  attaque  en  contestant  I'indivi duality,  i\  la  fois  clinique 
et  anatomique  du  carreau.  Ce  dernier  englobe  en  effet  d'apres  cet  auteur, 
des  faits  divers  tels  que:  ulcerations  intestinales  de  nature  tuberculeuse, 
peritonite  chronique,  les  feuillets  de  la  s(5reuse  pouvant  etre  enfiammes, 
rouges,  reunis  meme  par  des  points  d'adherences  avec  I'intestin.  Le  d6- 
membrement  etait  d^s  ce  moment  accompli.  II  fut  accentue  mieux  encore 
il  y  a  quelques  annees  par  M.  Marfan,  qui  eut  le  merite  d'aj outer  que,  au  nom- 

454 


LA   P^RITONITE   TUBERCULEUSE   DU    NOURRISSON. — WEILL  ET  PEHU.     455 

bre  des  causes  d'intumescence  du  ventre:  entente,  peritonite  chi'onique,  il 
fallait  compter  le  rachitisme. 

Au  surplus  quand  on  consulte  les  premiers  travaux  des  auteurs  sur  la 
tuberculose  infantile,  on  ne  trouve  que  peu  d'indications  sur  les  particular- 
ites  que  presente  cette  affection  dans  les  premiers  temps  de  la  vie,  et  moins 
encore  sur  la  peritonite  du  nourrisson.  Connele  (1829)  reunit  des  observa- 
tions recueillies  dans  le  service  de  ^I.  Tadelot,  y  joint  quelques  commen- 
taires,  mais  ne  tente  aucun  essai  nosographique.  Les  cas  visent  d'ailleurs 
surtout  des  enfants  ages  de  plus  de  deux  ans.  Memes  constatations  peuvent 
etre  faites  dans  les  publications  de  Papavoine  (1830)  qui  ne  considere  pas 
ia  tuberculose  aux  differents  ages;  dans  un  tableau  recapitulatif  il  men- 
tionne  seulement,  sans  autres  details:  enfants  de  deux  ans  au  moins. 
Toutefois  cet  auteur  a  le  merite  de  cette  remarque :  la  diffusion  des  lesions  est 
la  regie  dans  les  tuberculoses  du  nourrisson:  "Lorsque,  dit  il  les  tubercules 
se  developpent  dans  le  premier  age,  ils  le  font  presque  partout  a  la  fois  dans 
le  cerveau,  les  poumons,  le  tube  digestif,  les  glandes  lymphatiques  la  rate, 
le  foie,  les  sereuses." 

Les  premiers,  Rillet  et  Barthez,  signalent  qu'ils  ont  pu  relever  11  cas  de 
peritonite  tuberculeuse  chez  des  enfants  de  un  an  a  deux  ans  et  demi,  tout 
en  declarant  qu'elle  est  plutot  exceptionnelle  avant  4  ans.  Les  ouvrages 
ulterieurs  de  Berton  (1842)  Barrier  (1845),  puis  plus  tard  Cadet  et  Ganicourt, 
d'Espine  et  Pi  cot,  Baginski,  linger  etc.,  n'apportent  aucun  Element  nouveau. 
C'est  plutot  dans  des  publications  concernant  la  tuberculose  du  premier 
age  et  posterieures  aux  recherches  deja  mentionnees,  de  Landouzy  et 
Queyrat  que  Ton  peut  trouver  des  indications  utiles;  il  nous  est  impossible 
dans  cette  communication  de  les  citer  en  detail.  Deux  d'entre  elles,  plus 
recentes,  et  specialement  consacrees  k  la  therapeutique  medicale  ou  cliirur- 
gicale,  de  la  tuberculose  peritoneale  sont  tr^s  riches  en  documents  biblio- 
graphiques  frangais  ou  etrangers :  un  rapport  de  M.  A.  Broca  au  Congres  de 
Lis'oonne  (avril  1906)  et  un  travail  tres  complet  de  ]\I.  Schmid  (Jahrb.  f. 
Kind.  oct.  1907). 

Enfin  les  traites  classiques  de  ces  dernieres  annees  s'accordent  tous  pour 
reconnaitre  la  rarete  de  la  peritonite  tuberculeuse  du  premier  age.  C'est 
dans  ce  sens  que  concluent  les  articles  recents  de  Marfan,  Mery,  Weill, 
d'Espine  et  Picot  (etc.). 

IL  Si  la  peritonite  tuberculeuse  du  nourrisson  n'a  pas  davantage  appele 
I'attention  des  auteurs  il  faut  en  chercher  la  raison  dans  ce  fait  que  cette 
affection  est  assez  rare.     Mais  encore  faut-il  s'entendre  sur  ce  point. 

On  salt  que,  dans  le  premier  age,  c'est-a-dii-e  dans  les  deux  ou  trois  premieres 
annees  de  la  vie,  il  est  frequent  d 'observer  une  generalisation  de  la  tubercu- 
lose h  noml)re  d'organes.  C'est  ainsi  qu'on  trouve  d'ordinaire  des  granula- 
tions ou  des  tubercules  dans  les  differents  visceres,  non  seulement  au  niveau 


456  SIXTH    INTERNATIONAL   CONGRESS   ON    TUBERCULOSIS. 

des  poumons,  du  foie,  de  la  rate,  mais  encore  dans  les  centres  nerveux,  et  il 
est  de  connaissance  commune  que  brulant  les  etapes,  la  tuberculose  du 
nourrisson  fait  des  ravages  dans  I'organisme  tout  entier. 

Or,  si  Ton  pratique  I'autopsie  d'un  nourrisson  atteint  de  cette  maladie, 
il  n'est  pas  rare  de  trouver  des  tubercules,  ou  mieux  encore  des  granulations 
au  niveau  des  sereuses  pleurale  et  peritoneale.  Cette  derniere  est  souvent 
lesee  en  meme;  temps  que  les  visceres  abdominaux.  Les  bebes  atteints  de 
tuberculose  succombent  en  effet  a  une  poussee  granulique  totale,  generalisee; 
et  il  est  courant,  en  pareille  circonstance,  de  trouver  des  semis  de  granulations 
grises  ou  jaunes  confluentes  dans  les  feuillets  perihepatique,  sur  la  coupole 
diaphragmatique,  autour  de  la  rate,  ou  encore  sur  le  plancher  pelvieu.  Les 
granulations  sont  a  topographie  perivasculaire.  Si  les  granulations  pre- 
dominent  au  niveau  des  points  precites,  c'est  probablement  parcequ'il  y  a 
la  des  aires  de  circulation  plus  ralentie,  ou  les  edifications  bacillaires  peuvent 
plus  facilement  etre  realisees. 

Mais  la  n'est  point  la  tuberculose  peritoneale  vraie :  pour  que  celle-ci  soit 
constituee  il  faut  que  les  lesions  aient  eu  le  temps  de  faire  de  plus  importants 
ravages,  qu'il  se  soit  etabli  des  adlierences  entre  les  anses  intestinales  et  le 
peritoine  parietal,  qu'il  y  ait  des  lesions  intestinales  (anterieures  ou  con- 
temporaines)  que  se  soit  constitue  une  ascite  purulente,  toutes  particular- 
ites  anatomiques  sur  lesquelles  nous  insisterons  bientot.  En  un  mot,  il 
faut  que  la  tuberculose  du  peritoine  se  signale  cliniquement  par  une  physion- 
omie  symptomatique  bien  tranchee,  qu'elle  se  distingue  nettement  des  autres 
manifestations  bacillaires.  A  ce  titre,  mais  a  ce  titre  seulement,  la  tubercu- 
lose du  peritoine  peut  etre  nettement  individualisee. 

Si  Ton  se  place  k  ce  point  de  vue,  on  conviendra  que  les  observations 
legitimes  de  peritonite  tuberculeuse  chez  le  nourrisson  sont  plutot  rares. 
En  compulsant  des  travaux  deja  anciens  et  des  publications  r^centes,  nous 
n'avons  pu  en  r^unir  qu'une  centaine  qu'il  serait  impossible  de  citer  ici  dans 
leur  integrite. 

D'ailleurs  toutes  ne  sont  pas  d'egale  valeur.  La  plupart  figurent  dans  des 
travaux  relatifs  a  la  tuberculose  du  nourrisson  en  general,  et,  a  ce  titre, 
I'attention  n'a  pas  ete  appelee  specialement  sur  les  ph^nomenes  peritoneaux. 
Les  details  cliniques  sont  assez  brefs.  D'autres  sont  plus  completes,  et, 
somme  toute,  utilisables  pour  I'etude.  Mais,  dans  bien  peu  d'entre  elles, 
I'observation  pendant  la  vie  du  petit  malade  puis  le  protocole  d'autopsie, 
sont  suffisamment  complets.  II  nous  a  paru  necessaire  de  faire  des  main- 
tenant  des  reserves,  concemant  le  "materiel"  utilisable  pour  la  presente 
etude. 

III.  Avant  d'aborder  I'^tude  clinique  de  la  tuberculose  peritoneale  du 
nourrisson,  il  nous  semble  utile  de  d^crire  I'anatomie  pathologique  de  cette 
affection. 


LA   PERITONITE   TUBERCULEUSE  DU  NOURRISSON. — WEILL  ET  PEHU.        457 

1.  Un  fait  saillant  doit  etre  degage.  La  maladie  se  caracterise  d'or- 
dinaire  par  des  tubercules  crus  ou  ramoUis,  par  consequent,  sous  la  forme 
caseeuse.  La  modalite  fibreuse  est  plutot  rare,  a  peu  pres  inconnue ;  cela 
n'est  point  pour  surprendre,  car  on  sait  bien  que  la  tuberculose  du  nourrisson 
affecte  d'ordinaire  cette  allure,  qu'elle  est  un  "caseie"  suivant  I'expression 
de  I'un  de  nous  (E.  Weill). 

II  en  decoule  cette  consequence  que  la  forme  ascitique  pure,  comparable 
a  rhydarthrose  sereuse  ou  sero-fibrineuse  d'une  jointure  est  fort  rare  dans 
la  peritonite  tuberculeuse  du  premier  age,  qu'on  y  voit  au  contraire  le  plus 
habituellement,  des  lesions  caseeuses  d'abord,  puis  ramollies  et  ulterieure- 
ment  envahies  par  des  infections  secondaires. 

Les  alterations  anatomiques  sont  ainsi  plus  ou  moins  diffuses  suivant 
I'intensite  du  processus.  Debutant  en  divers  points  de  la  sereuse  sur  le 
feuillet  parietal,  ou  au  niveau  des  replis  visceraux  (mesentere,  epiploons)  elle 
amene  des  coalescences  entre  le  peritoine  et  les  visceres  abdominaux,  partic- 
ulierement  avec  I'intestin.  Ainsi  peuvent  se  constituer  des  foyers  enkystes, 
ou  communiquant  avec  le  reste  de  la  cavite.  Ces  foyers  peuvent  meme  se 
collecter  en  certains  points  de  predilection,  I'ombilic  par  exemple,  comme 
cela  est  frequemment  observe  dans  la  peritonite  de  la  seconde  enfance. 

Le  contenu  de  ces  foyers  est  constitue  par  du  pus  ou  de  la  serosite  louche. 
Generalement  le  pus  est  floconneux,  mal  lie,  analogue  a  celui  qui  resulte  des 
suppurations  bacillaires. 

Les  6panchements  abdominaux  enkystes  ou  libres,  ne  sont  pas  cependant 
tou jours  purulents.  II  est  parfois  possible  de  retirer  un  liquide  serofibrineux 
simple  analogue  a  celui  des  pleuresies  tuber culeuses.  L'un  de  nous  a  pu 
suivre  ainsi  un  cas,  suivi  de  guerison,  chez  un  enfant  de  20  mois,  oii  la  ponc- 
tion  permit  d'^vacuer  un  liquide  a  peu  pres  limpide,  de  coloration  verdatre, 
dans  lequel  la  cytologie  mit  en  evidence  des  lymphocytes  en  quantite  tres 
predominante. 

2.  Les  lesions  de  I'intestin  sont  assez  constantes  au  cours  de  la  peritonite 
tuberculeuse  du  premier  age. 

On  y  peut  observer  des  granulations,  des  tubercules,  ou  des  ulcerations 
intestinales  qui  ne  different  pas  des  alterations  bacillaires  communes.  Assez 
couramment  on  note  des  perforations  intestinales,  les  unes  fennees  par  des 
adherences,  d'autres  baignant  dans  un  foyer  suppure.  II  est  meme  souvent 
difficile  de  dire,  si,  en  pareille  circonstance,  les  lesions  du  peritoine  sont 
anterieures  ou  posterieures  a  I'ulc^ration  intestinale;  car  il  est  parfaite- 
ment  rationnel  d'admettre  que  I'intestin  s'^tant  perform,  il  s'est  fait  une  peri- 
tonite secondaire,  banale,  comme  au  cours  d'une  dothienenterie  ou  dans  un 
processus  a  caractcre  ulc^ratif.  Mais  la  presence  de  nombreux  tubercules 
sur  d'autres  points  du  peritoine  permet  de  trancher  la  question. 


458  SIXTH    IXTERNATIONAL   CONGRESS    ON   TUBERCULOSIS. 

3.  Une  particularite  doit  etre  mise  en  relief:  c'est  la  presence,  relative- 
ment  frequente,  de  lesions  caseeuses  dans  Ics  organes  genitaux  des  deux  sexes. 

Chez  la  petite  fille  il  n'est  point  rare  de  constater  la  d^generescence 
caseeuse  du  tractus  genital:  trompes  d'abord,  ovaires  ensuite,  uterus.  Wol- 
stein  (1900)  Neter  (1903)  ont  insiste  sur  ces  faits.  Meme  il  n'est  pas  ex- 
ceptionnel  de  trouver,  concurremment,  des  lesions  externes:  ulcere  tuber- 
culeux  du  vagin  comme  Demme  en  a  public  des  exemples  (1885  et  1887). 
Cette  trouvaille  n'est  pas  pour  surprendre  depuis  que  Cornil  a  insiste  sur 
la  frequence  de  la  tuberculose  genitale  et  sp^cialement  sur  la  salpingite 
caseeuse  dans  la  peritonite  bacilliare  des  adolescents  ou  des  adultes.  Cettc 
degenerescence  des  trompes  est  souvent  bilaterale.  Malgr6  leur  "sommeii 
physiologique  "  ces  organes  peuvent  done  etre  atteints  par  I'infection  tuber- 
culeuse. 

Les  organes  males  peuvent  egalement  etre  interesses.  Deja  D.  MoUiere 
et  Augagneur  (Diet.  Dechambre)  avaient  signale  la  coincidence  de  la  tuber- 
culose testiculaire  et  du  "  carreau".  Hutinel  et  Deschamps  (1891)  ont  releve 
la  peritonite  bacilliare  dans  4  cas  sur  6.  La  persistance  du  canal  vagino- 
peritoneal est  evidemment  une  cause  predisposante  car,enpareille  occurrence, 
I'infection  ascendante  gagne  le  peritoine  par  le  canal  deferent.  II  se  pent 
egalement  que  la  tuberculose  interesse  les  vesicules  seminales  ou  la  prostate; 
mais  le  fait  est  peu  frequent  (Broca) . 

Apropos  de  ces  cas  de  tuberculose  genitale  on  peut  se  demander  si  I'in- 
fection peritoneale  est  primitive  ou  secondaire ;  mais  comme  pour  I'intestin, 
il  est  assez  difficile  de  resoudre  categoriquement  le  probleme.  II  se  peut 
lieu,  d'ailleurs,  que  dans  un  cas  comme  dans  T autre,  I'infection  soit  con- 
temporaine  et  effectuee  par  la  voie  sanguine. 

4.  Enfin,  comme  au  cours  de  la  tuberculose  du  nourrisson,  il  est  de  regie 
d'observer  des  alterations  diffusees  aux  autres  organes.  Le  foie,  la  rate, 
les  reins,  les  poumons,  etc.,  sont  leses,  on  y  trouve  des  granulations  ou  des 
tubercules.  Les  ganglions  mesenteriques  ont  souvent  subi  la  transformation 
caseeuse  comme  d'ailleurs,  les  ganglions  lombaires  et  mediastinaux.  La 
generalisation  des  lesions  prouve  bien  que,  dans  ces  conditions,  la  maladie 
ne  peut  guerir.  Inverscment  on  peut  soupgonner  sans  I'affirmer  toutefois, 
que,  dans  les  cas  curables,  la  maladie  se  cantonne  au  peritoine,  et  vespecte  les 
visceres  abdominaux  ou  thoraciques.  L'extension  a  plusieurs  organes 
fait  que  la  maladie,  comme  nous  I'^tablirons,  a  une  marche  generalement 
rapide:  la  chronicite  et  revolution  lente  ne  sont  point  dans  ses  allures 
naturelles;  il  en  resulte  qu'on  n'a  pas  observe  la  degenerescence  amyloide 
qui  accompagne  au  contraire,  certaines  formes  tardives,  prolongees,  de  la 
peritonite  bacillaire. 

En  resume,  la  tuberculose  du  peritoine,  chez  le  nourrisson,  se  carac- 
terise  anatomiquement  par  la  predominance  manifeste  de  la  forme  caseeuse, 


LA    PERITONITE   TUBERCULEUSE   DU  NOURRISSON. — WEILL  ET   PEHU.    459 

par  la  generalisation  des  lesions  et  par  la  coincidence  frequente  de  lesions 
bacillaires  dans  I'appareil  genital  masculin  ou  feminin. 

IV.  La  symptomatologie  de  cette  affection  a  des  caracteres  assez  tranches 
pour  qu'on  puisse  sinon  affirmer,  du  moins,  soupgonner  son  existence. 

Le  debut  se  fait  par  des  phenomenes  douloureux  qui  se  traduisent  par 
une  expression  intermittente  de  souffrance  sur  le  visage  du  petit  malade  ou 
par  une  flexion  des  cuisses  sur  I'abdomen,  comma  dans  les  peritonites  du 
jeune  age.  Les  parents  ont  en  general,  remarque  une  augmentation  pro- 
gressive du  volume  du  ventre.  Toutefois  ce  symptome  ne  peut  etre  con- 
sidere  comme  ayant  une  valeur  pour  le  diagnostic,  car  ces  nourrissons  peuvent 
avoir  de  I'intumescence  abdominale  par  le  fait  d'un  rachitisme  ancien  et  de 
poussees  enteritiques  recidivantes.  Pour  que  ce  symptome  soit  pris  en 
serieuse  considerations,  il  faut  qu'il  soit  tres  prononce,  que  le  ventre  subisse 
une  augmentation  notable;  il  est  superflu  de  dire  que  le  meteorisme  est 
proportionnel  a  la  quantite  de  liquide  epanche  et  qu'il  est  surtout  accentue 
dans  les  formes  ascitiques.  Des  vomissements,  de  la  diarrhee  sont  frequem- 
ment  mentionn6s.  L'etat  general  est  souvent  tres  precaire,  I'amaigrisse- 
ment  progressif. 

A  la  periode  d'etat,  la  symptomatologie  ne  differe  pas  beaucoup  de  ce 
qu'elle  est  dans  les  peritonites  tuberculeuses  survenant  chez  les  enfants  plus 
ages.  On  y  trouve  en  effet  I'augmentation  de  volume  du  ventre,  le  meteorisme, 
la  circulation  coUaterale  qui  existait  nettement  dans  une  de  nos  observations 
et  qui  permit  un  diagnostic  precoce.  La  diarrhee  et  les  troubles  digestifs 
figurent  assez  souvent:  ils  ne  sont  point  constants  cependant,  la  diarrhee 
paraissant  en  effet  dependre  des  lesions  intestinales  concomitantes. 

L'examen  direct  denote  quelquefois  de  la  douleur  a  la  palpation;  mais 
cette  derniere  est  attenuee  dans  la  majorite  des  cas.  On  peut  noter  du  flot 
ut^ral  et  lombo-abdominal  (signe  de  Bard).  Parfois  I'ascite  etant  cloison- 
nee  on  n'obtient  pas  de  modification  par  les  changements  de  position  du 
petit  malade.  Si  I'epanchement  abdominal  n'est  pas  trop  abondant  ou 
pourra  percevoir  une  sensation  d'empatement  diffus,  assez  rarement  des 
gateaux  abdominaux  comme  dans  la  peritonite  des  adolescents.  Wider- 
hofer,  cite  par  M.  Marfan,  pretend  qu'on  peut  senter  sous  la  peau  du  ventre 
et  sur  le  trajet  des  lymphatiques  de  petits  noyaux  durs,  roulant  sous  le 
doigt,  et  qui  seraient  des  ganglions  lymphatiques  tuberculeux. 

Un  symptome  parfois  rencontr6,  et  qui  aurait,  d'apres  Vierordt  une  valeur 
diagnostique  assez  grande,  est  I'ecoulement  vulvaire  do  nature  purulente: 
il  pourrait,  il  est  vrai,  etre  causd  par  une  ulcdration  tuberculeuse  des  grandes 
16vres  sans  que,  pour  cela  le  pdritoine  soit  atteint. 

Le  toucher  rectal  ne  doit  pas  etre  oublie;  il  renseignera  parfois  surl'ex- 
istence  de  lesions  p6riur6thrales,  au  niveau  de  la  prostate  ou  des  vesicules 
s^minales. 


460  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

Dans  la  majorite  des  cas  Taffection  est  apyretique,  comme  d'ailleurs  dans 
la  tuberculose  du  nourrisson,  Cependant  ce  symptome  ne  parait  pas  avoir 
6te  suffisamment  recherche:  il  n'est  en  general  pas  mentionn^  dans  les 
observations  que  nous  avons  pu  compulser. 

Enfin :  parmi  les  signes  caract^ristiques  de  I'affection,  il  faut  citer  I'exis- 
tence  d'une  fistule  ombilicale.  On  connait  les  tendances  qu'ont  les  suppur- 
ations abdominales,  de  nature  tuberculeuse,  a  se  deriger  vers  rombilic. 
A  ce  niveau  la  peau  rougit,  I'oedematie,  puis  la  collection  s'ouvre  a  I'ex- 
t^rieur;  laissant  une  fistule  persistante  par  laquelle  s'ecoulent  ulterieurement 
du  pus  et,  meme  des  matieres  f Scales — Schrotter  (1903)  insistait  r^cemment 
sur  ces  faits  auxquels  il  a  consacre  une  importante  etude. 

Avec  ces  signes  locaux,  on  note  k  distance  des  ph^nomenes  tres  signi- 
ficatifs:  des  ganglions  peripheriques  peuvent  i^tre  envahis  par  la  tuberculose 
et  se  presenter  sous  la  forme  de  tumefactions  appreciables  au  niveau  du  cou, 
des  aines  et  des  aisselles.  Le  foie,  la  rate  sont  souvent  hypertrophies. 
L'examen  des  poumons  n'est  pas  toujours  positif,  car  on  sait  qu'a  cet  age 
de  la  vie,  I'auscultation  ne  revele  pas  des  signes  tres  probants.  Les  petits 
malades  sont  souvent  porteurs  d'6coulements  d'oreille  qui  peuvent  ressortir 
a  une  infection  banale  de  I'oreille  moyenne  si  commune  dans  les]  ^tats 
cachectiques  de  la  premiere  enfance,  ou  encore  a  une  tuberculose  du  rocher. 
La  presence  de  gommes  sous  cutanees  avec  leur  siege  habituel  au  niveau 
des  fesses  ou  des  members  inf^rieurs  n'est  d'ordiniare  pas  mentionnee. 

Quant  a  I'etat  general  il  est  le  plus  souvent  precaire.  Les  nourrissons 
pr^sentent  I'aspect  de  I'atrophie  ou  de  I'athreptie  chroniques  avec  emacia- 
tion marquee,  peau  fletrie  et  de  teinte  plombee,  excavation  des  yeux,  en  un 
mot  avec  le  cortege  habituel  et  si  impressionnant  de  la  grande  cachexie. 

L'evolution  de  la  maladie  se  fait  d'ordinaire  vers  la  mort,  celle-ci  sur- 
vient  dans  le  marasme,  ou  bien  elle  est  amende  par  une  infection  secondaire 
souvent  a  determination  broncopulmonaire;  ou  encore  c'est  une  m^ningite 
terminale  qui  emporte  le  petit  malade.  L'affection  est  en  general,  assez 
rapide  dans  ses  principales  phases :  ce  qui  est  la  consequence  de  la  diffusion 
des  lesions. 

Toutefois,  la  guerison  est  possible;  les  formes  ascitiques  sont  curables. 
L'un  de  nous  a  pu  observer  un  an  apr^s  la  maladie,  un  cas  de  ce  genre  dans 
lequel  l'affection  caracteristique  dans  ses  principaux  symptomes,  avait  6t6 
affirmee  par  I'existence  d'une  lymphocytose  du  liquide  d'ascite  retird  par 
ponction.  Le  ventre  avait  recouvre  toute  sa  souplesse;  I'^tat  general  du 
malade  etait  excellent.  Schmidt  dans  son  r<§cent  m^moire  (1907)  a  cite 
plusieurs  cas  suivis  de  guerison  constatee  apres  plusieurs  ann^es.  Meme  les 
formes  cas6euses  et  suppurees  peuvent  parfois  etre  curables.  Toutefois 
cette  Eventuality  est  plutot  rare;  et  le  pronostic  peut  etre  considere  toujours 
comme  serieux,  sinon  tr6s  grave. 


LA   P^RITONITE   TUBERCULEUSE   DU   NOURRISSON. — WEILL  ET  PEHU.    461 

II  est  superflu  cle  repeter  une  fois  encore  que  la  diffusion  des  lesions  a 
plusieurs  organes,  la  possibilite  d'infections  secondaires  constituent  des 
obstacles  a  une  reparation  definitive. 

V.  Si  le  diagnostic  de  la  peritonite  bacillaire  est  generalement  fait  dans 
la  deuxieme  enfance,  il  n'est  pas  aussi  aise  quand  il  s'agit  du  premier  age. 
A  cette  periode  en  effet  le  "gros  ventre"  est  d'une  constatation  fre- 
quente,  presque  banale,  rneme,  pourrait  on  dire  dans  les  services  d'hopital. 
Or,  il  s'agit  d'assigner  a  cette  intumescence  abdominale  sa  veritable  cause  et 
le  probleme  n'est  pas  toujours  d'une  solution  facile. 

Apropos  de  I'historique,  nous  avons  rappele  les  discussions  anciennes  sur 
la  nature  vraie  du  carreau.  Baumes  I'avait  considere  comme  du  a  une 
tuberculose  entero-peritoneale;  mais  sa  conception  n'eut  qu'une  duree 
ephemere  puisque  un  peu  plus  de  30  ans  apres  ses  publications  Guersant 
demontrait  qu'il  s'agissait  de  cas  desparates  englobant  des  faits  de  peri- 
tonite bacillaire,  d'enterite  a  forme  ulcereuse  due  au  bacille  de  Koch  et  enfin 
d'adenopathie  mesenterique  de  meme  nature.  M.  Marfan  (1895)  y  a  ajoute 
cette  notion  que  beaucoup  de  gros  ventres  chez  le  nourrisson  etaient  dus  a 
une  dj^spepsie  gastro-intestinale  ancienne,  avec  poussees  diarrheiques, 
ayant  determine  un  allongement  atonique  de  I'intestin  dans  ses  differentes 
portions.  Le  demembrement  de  la  pretendue  maladie  est  done  depuis 
longtemps  effectu^. 

En  presence  d'un  abdomen  augmente  de  volume,  souvent  on  ne  pent 
s'empecher  de  songer  a  I'existence  possible  d'une  peritonite  bacillaire. 
Certains  nourrissons  presentent  un  ventre  distendu,  faisant  un  relief  con- 
siderable tympanise;  s'il  s'y  ajoute  un  etat  cachectique,  ou  atrophique, 
I'hesitation  est  legitime.  Cependant  le  gros  ventre  des  rachitiques  pre- 
sente  une  sonoritc  exageree  dans  toute  son  etendue  et  point  la  matite  de- 
plagable  accompagnee  d'un  flot  lateral  ou  lombo-abdominal  qui  est  au  con- 
traire  I'apanage  des  epanchements  ascitiques  accompagnant  la  tuberculose 
p^ritoneale.  Pas  de  circulation  coUaterale.  La  palpation  denote  une 
resistance  generalisee,  mais  ancune  sensation  d'empatement  ou  d 'indura- 
tion partiels,  pas  de  gateaux  constatables.  L'examen  des  autres  organes  est 
en  general  negatif:  on  ne  peut  faire  etat  des  symptomes  digestifs  sura- 
joutes:  diarrhee  ou  vomissements  car  ils  peuvent  exister  dans  I'une  ou 
r  autre  de  ces  maladies. 

Certaines  cirrhoses  spleno-h^patiques  d'origine  heredo-syphilitique  peu- 
vent en  imposer  pour  une  peritonite  tuberculeuse  a  forme  ascitique.  Ce- 
pendant elles  sont  fort  rares;  car  la  syphilis  amene  plutot  de  rh(5pato  ou 
de  la  spl^no-megalie  sans  ascite;  I'etat  de  duret^  du  foie  quand  cet  organe 
peut  etre  facilement  explore  serait  evidemment  un  signe  d'une  grande  im- 
portance. 

Les  differentes  formes  de  peritonite  non  tuberculeuses  ont  evidemment 


462  SIXTH   INTERNATIONAL   CONGRESS    ON   TUBERCULOSIS. 

quelques  points  communs:  epanchement  abdominal,  meteorisme,  gon- 
flement  du  ventre,  phenomenes  douloureux,  etc.  Le  nourrisson,  on  le  salt, 
est  susceptible  de  presenter  des  peritonites  appendiculaires  pneurao-cocciques 
ou  gono-cocciques.  Mais  I'allure  de  ces  dernieres  est  g^neralement  aigue, 
a  grand  fracas  avec  invasion  brusque  ou  rapide.  La  fievre  s'allume  plus 
facilement.  La  maladie  est  plus  limitee,  non  diffusee  a  tout  I'organisme. 
La  ressemblance  est  done  assez  lointaine  et  il  suffit,  sans  y  insister  davantage, 
de  signaler  cette  erreur  possible. 

Assez  semblable  a  celle  de  la  peritonite  bacillaire  chronique,  est  la  symp- 
tomatologie  des  tumeurs  abdominales,  du  sarcome  de  certains  organes, 
tels  que  rein  ou  intestin.  M.  Variot  (1904)  a  cru  tout  d'abord  a  un  neo- 
plasme  du  rein  chez  un  enfant  de  18  mois  qui  presentait  du  meteorisme  a 
droite,  tandis  que  dans  la  partie  gauche  du  ventre  on  sentait  une  masse  dure, 
male,  bosselee  et  fluctuante  par  endroits.  Dans  d'autres  cas  la  confusion 
a  ete  faite  avec  une  hydronephrose  d'un  rein;  ou  encore  avec  un  kyste  con- 
genital de  cet  organe.  II  est  certain  qu'une  semblable  erreur  peut  etre 
commise,  comme  elle  Test  chez  I'adulte  quand  il  s'agit  d'etablir  un  diag- 
nostic differentiel  avec  un  kyste  ovarique.  Les  elements  qui  rendent  possible 
cette  distinction  nous  parraissent  etre  que  dans  la  peritonite  tuberculeuse 
I'empatement  ou  les  signes  de  tumeur  sont  plus  diffus  et  que  la  matite  est 
deplagable.  Les  symptomes  concomitants  (presence  de  manifestations 
tuberculeuses  exterieures,  sur  la  peau  ou  sur  les  ganghons),  I'etude  de  la 
courbe  thermique  sont  des  elements  de  grande  probabilite  en  faveur  de  la 
peritonite  bacillaire. 

II  est  beaucoup  plus  malaise  de  differencier  la  peritonite  elle  meme  et 
la  tuber culose  intestinale  a  forme  ulcereuse.  S'il  existe  un  epanchement 
ascitique,  il  y  a  beaucoup  de  chances  pour  que  la  sereuse  soit  interessee. 
Mais  peut  on  pretendre  que  I'intestin  n'est  pas  lese?  II  serait  temeraire  de 
Taffirmer:  d'autant  que  les  lesions  se  diffusent  facilement  de  la  sereuse  a 
I'intestin,  comme  en  temoignent  les  autopsies.  Quant  a  I'adenopathie 
mesenterique,  elle  n'a  pas  nous  semble-t-il  d'existence  clinique  reelle.  Son 
histoire  se  confond  plutot  avec  celle  de  la  tuberculose  intestinale  dont  elle 
est,  cf  ordinaire  la  consequence.  II  peut  se  faire  cependant  qu'elle  se  presente 
k  I'etat  isole,  sous  la  forme  de  tumeurs  de  volume  variant  de  celui  d'une 
noissette  a  celui  d'un  ceuf  de  pigeon,  perceptibles  sous  la  parol  amincie  et 
flasque  de  I'abdomen,  predominant  a  droite  au  niveau  de  Tangle  ileo-coecal. 
Mais  en  pareil  cas,  ces  tumeurs  ne  s'accompagnent  pas  d'ascite,  elles  sont 
assez  franchement  limitees;  elles  resistent  a  I'administration  de  lavements 
repetes  et  profondement  evacuateurs;  et  elles  ne  se  revelent  par  aucun 
symptome  fonctionnel  s'il  n'y  a  pas  de  lesions  intestinales  en  activite. 

C'est  done,  en  derniere  analyse,  surtout  avec  le  gros  ventre  des  rachi- 
tiques,  avec  les  tumeurs  abdominales  que  la  confusion  est  possible.     Nous 


LA    PERITONITE   TUBERCULEUSE    DU    NOURRISSON. — WEILL  ET  PEHU.    463 

avons  indique  quels  sont  les  moyens  dont  le  clinicien  dispose  pour  arriver  a 
un  diagnostic  precis. 

II  est  superflu  d'ajouter  qu'on  ne  devra  point  negliger  les  procedes  de 
laboratoire:  particulierement  la  recherche  de  la  formule  cyi^ologique  du 
liquide  epanche,  s'il  y  a  ascite,  des  bacilles  dans  les  selles,  et  surtout  les 
reactions  generales  ou  locales  produites  par  la  tuberculine :  injection  sous- 
cutanee  ou  intra-dermique  de  cette  derniere,  cuti  ou  ophtalmo  reaction,  etc. 

VI.  Sur  le  traitement  de  la  peritonite  bacillaire  chez  le  nourrisson  il  ne 
nous  parait  pas  necessaire  de  nous  etendre  bien  longuement.  Les  indications 
therapeutiques  sont  les  memes  que  lorsqu'il  s'agit  d'enfants  plus  ages  a 
quelques  varaintes  pres.  La  medication  interne  se  reduit  a  des  toniques 
generaux,  comme  dans  la  tuberculose  viscerale,  d'ailleurs. 

S'il  s'agit  d'une  forme  ascitique,  rarement  observee,  comme  nous  I'avons 
dit,  il  faudra  pour  pratiquer  une  paracentese  se  guider  sur  le  degre  de  dis- 
tension du  ventre.  Si  celui-ci  n'est  pas  tres  marque  mieux  vaut  differer 
la  ponction  qui  pent  soustraire  une  masse  importante  de  serosite,  d'un 
deperdition  prejudiciable  a  I'organisme.  Mais  la  paracentese  pent  etre 
rendue  obligatoire  par  la  distension  extreme  du  ventre,  le  refoulement  des 
visceres,  il  faut  intervenir  comme  dans  les  ascites  volumineuses. 

Si  la  tuberculose  peritoneale  est  caseeuse  et  suppuree  la  question  de  la 
laparotomie  se  pose;  il  pent  etre  en  effet  plausible  d'evacuer  le  pus,  de 
drainer  la  cavite  abdominale;  mais  I'operation  est  tres  grave  et  les  succes 
fort  rare.  La  proportion  de  guerisons  definitives  ou  prolongees  est  minime. 
Au  surplus  on  est  souvent  empeche  d'intervenir  par  la  cachexie  du  petit 
malade,  par  la  generalisation  des  lesions  qui  rendent  tout  acte  operatoire 
dangereux  ou  inutile. 


TUBERCULOSIS  OF  THE  PERICARDIUM  IN  CHILDREN. 

By  Joseph  S.  Wall,  M.D., 

Professor  of   Physiologj',  Georgetown   University;    Pediatrist  to   the   Providence  and  Foundlings' 
Hospitals;  Assistant  Physician  to  the  Children's  Hospital,  Washington,  D.  C. 


Tuberculosis  of  the  pericardium  may  be  encountered  as  a  mere  incident 
in  the  course  of  pulmonary  or  general  tuberculosis,  with  latent  symptoms 
and  without  lesions  of  sufficient  importance  to  draw  attention  to  the  peri- 
cardial membrane  as  an  especially  vulnerable  part  in  sharing  in  the  ravages 
of  the  disease. 

To  such  types  as  these  some  would  apply  the  designation  "tuberculosis 
of  the  pericarcUum,"  whereas  the  term  "tuberculous  pericarditis"  is  re- 
stricted to  that  class  in  which  the  evidences  of  pericardial  disease  are  of 
such  moment  as  to  attract  especial  attention  during  life  or  at  autopsy.  In 
fact,  it  is  not  infrequently  found  that  the  clinical  picture  of  pericarditis  is 
so  distinct  that  other  associated  manifestations  of  tuberculosis  are  masked, 
and  the  symptoms  are  so  overwhelmingly  cardiac  that  pericarditis  of  tuber- 
cular origin  may  be  given  clinical  consideration  with  about  as  much  fitness 
as  meningitis  from  a  similar  cause. 

Tuberculous  involvement  of  the  pericardium  has  been  encountered  in 
varying  proportions  by  different  observers,  a  very  high  percentage  being 
claimed  by  the  French  writers — one-third  of  all  cases  of  tuberculosis,  accord- 
ing to  Chappe,  and  in  smaller  percentages  by  others.  Still,  in  769  autopsies 
on  children  under  twelve,  found  37  instances  of  tuberculosis  of  the  peri- 
cardium, almost  5  per  cent.,  in  subjects  dead  from  general  causes.  To 
indicate  its  frequency  in  proportion  to  pericarditis  from  other  causes,  Chappe 
c^uotes  Hamburger,  who  found  12  cases  out  of  57  tuberculous;  Leudet, 
8  out  of  36;  Weill,  5  out  of  24;  and  his  personal  observation,  that  one-fourth 
are  tuberculous. 

Tuberculous  pericarditis,  from  its  frequency  and  from  its  occasional 
absolute  predominance  over  other  lesions  in  the  course  of  tuberculosis, 
might  be  considered  a  distinct  morbid  entity,  possessing  enough  differential 
characteristics  to  prove  an  engaging  study. 

Etiology. 
Pericardial  tuberculosis  makes  presumptive  the  presence  of  a  disease 
focus  elsewhere,  of  which  this  malady  is  the  offspring,  and  those  few  reported 

464 


TUBERCULOSIS    OF   THE    PERICARDIUM   IN    CHILDREN. — WALL.  465 

cases  of  primary  involvement  of  the  sac  must  have  been  cryptogenetic, 
and  primary  only  in  the  sense  that  primitive  clinical  disturbances  occurred 
in  this  region. 

An  antecedent  history  of  family  tuberculosis  is  sometimes  elicited, 
and  in  a  majority  of  cases  such  precursors  as  measles,  scarlatina,  diphtheria, 
exhausting  intestinal  maladies,  pneumonia,  and  tuberculous  disease  of  the 
lungs  and  pleurae  are  seen. 

The  frequency  of  measles  in  the  anamnesis  of  tuberculous  pericarditis 
is  marked,  and  the  tendency  to  tuberculosis  of  the  bronchial  glands  after 
this  exanthem  is  strongly  suggestive.  The  cause  par  excellence  is  tubercu- 
losis of  the  mediastinal  glands.  This  adenopathy  must  be  regarded  as  the 
source  of  infection  in  most  cases  of  tuberculosis  of  the  pericardium,  and  as 
the  almost  certain  factor  in  such  as  apparently  arise  de  novo.  Osier  has 
stated  that  the  involvement  of  the  pericardium  is  the  gradual  result'  of 
inflammation  by  continuity  and  contiguity,  while  Colrat  has  suggested 
the  mechation  of  the  lymphatics. 

The  most  striking  pathological  lesions  in  cases  coming  to  autops}^  are 
those  of  induration  and  caseation  of  the  tracheobronchial  and  peribronchial 
glands,  often  with  matting  of  the  adjacent  structures.  The  especial  ha- 
bility  of  children  to  disease  of  the  mediastinal  glands  would  explain  the 
comparative  frequency  of  tuberculous  pericarditis  in  those  of  tender  years, 
as  compared  to  adult  life. 

In  the  records  of  reported  cases,  where  the  influence  of  sex  was  noted, 

the  distril^ution  between  boys  and  girls  has  been  about  equal — sixteen 

males  and  nineteen  females.     The  age  of  those  affected,  when  given,  has 

varied  as  follows : 

1  to    3  years 4 

3  to    5  years - 9 

5  to    7  years 4 

7  to  10  years 9 

10  to  15  years 18 

Total 48 

Pathology. 

The  lesions  of  least  magnitude  are,  naturally,  those  met  in  "incident 
cases,"  which  have  given  rise  to  no  clinical  symptoms  before  death  and  are 
probably  often  overlooked  at  autopsy. 

On  opening  the  pericardium,  its  lack  of  luster  may  attract  attention, 
and  the  surface  may  present  an  opalescent,  sometimes  a  mother-of-pearl, 
appearance;  in  other  instances,  scattered  over  a  surface  not  especially 
lusterless  there  are  areas  of  a  yellowish  or  milky  nature,  at  times  raised 
above  the  surface  to  form  plaques  not  unlike  those  seen  in  the  aorta  in  disease 
of  its  endothelium. 


466  SIXTH    INTERNATIONAL   CONGRESS    ON   TUBERCULOSIS. 

In  the  mild  types,  scattered  tubercles,  with  but  little  exudate  into  or 
on  the  membrane,  are  seen  studding  both  visceral  and  parietal  layers. 
When  the  process  is  more  virulent,  the  macroscopic  appearances  are  more 
pronounced.  There  are  thickening  of  the  pericardium  and  deposit  of  false 
membrane  upon  its  surfaces,  the  lighter  types  showing  a  thin,  delicate 
exudate,  milky  or  yellowish  in  color,  which,  in  its  early  stages,  may  be 
stripped  off  with  ease  and  present  little  hindrance  to  the  separation  of  the 
pericardial  layers. 

In  older  types,  with  but  little  serous  exudate,  there  must  arise,  in  conse- 
quence, adhesion  of  the  layers,  which  are  sometimes  fragile  and  yield  the 
"bread-and-butter"  pericardium  on  forcible  separation — the  so-called 
villous  pericarditis;  in  other  cases,  their  organization  is  so  firm  and  dense 
that  separation  is  impossible. 

The  site  of  both  exudate  and  adhesions  is,  by  preference,  toward  the 
base,  the  less  mobile  part  of  the  heart,  for  here  may  be  found  partial  sym- 
physis with  apical  fluid,  and  this  is,  furthermore,  explanatory  of  the  basic 
location  of  pericardial  murmurs,  when  such  are  present. 

It  has  been  claimed  by  some  that  restitutio  ad  integrum  can  occur 
when  the  inflammatory  process  becomes  arrested  at  an  early  period,  with 
probably  delicate,  poorly  organized  exudates  within  the  sac,  but  such  an 
outcome  must  rarely  be  possible,  considering  the  ordinary  march  of  tuber- 
culous inflammation,  which,  though  less  virulent,  is  more  prolonged  and 
tenacious  than  that  resulting  from  other  infections  to  which  the  pericardium 
is  liable. 

With  plastic  deposits,  there  is  often  extreme  vascularity,  with  resultant 
liabiUty  to  hemorrhagic  exudates,  so  frequently  seen  in  tuberculous  peri- 
carditis. The  tendency  to  hemorrhage  may  be  further  increased  if  the  false 
membrane  is  reticulated  or  lacunar  in  character,  which  is  not  infrequently 
the  structural  texture  of  many  deposits.  These  spaces  often  contain  red 
blood-cells,  resulting  from  minute  extravasations  from  the  newly  formed 
capillaries  (Sergent). 

Not  only  is  there  increase  in  thickness  of  the  pericardium  by  successive 
additions  to  its  serous  face  by  inflammatory  exudate,  but  in  the  opposite 
direction,  toward  the  myocardium,  there  is  round-celled  infiltration,  with 
increased  width  of  the  membrane,  so  that  it  may  attain  a  breadth  of  from 
five  to  ten  millimeters,  or,  in  long-standing  cases,  the  inflammatory  indura- 
tion may  form  a  dense  fibrous  sheathing,  four  to  six  centimeters  in  thickness. 
This  enormous  thickening  is  met  in  conjunction  with  a  like  induration  of  the 
mediastinal  structures,  the  pleurae,  and,  not  infrequently,  of  the  capsule 
of  Glisson,  and  forms,  in  fact,  an  anatomical  entity,  characterized  by  exten- 
sive fibrosis  of  adjacent  and  neighboring  organs. 

The  microscopical  appearances  of  a  tuberculous  pericardium  h?ive  been 


TUBERCULOSIS    OF   THE    PERICARDIUM   IN   CHILDREN. — WALL.  467 

clearly  described  by  Sergent,  who  has  demonstrated  marked  thickening 
of  the  serous  membrane  and  of  the  subserous  tissue,  with  fibrosis  of  its 
constituent  arteries  and  veins.  On  the  parietal  wall,  the  serous  layer 
is  separated  from  the  subserous  by  a  zone  of  embryonal  cells  inclosing  many 
small  vessels.  He  has  also  described  well  the  lacunar  structure  of  the 
fibrinous  deposit  and  the  extreme  vascularity  of  the  lacunar  walls  with 
bloody  extravasations  into  their  vacuolated  spaces.  He  was  unable  to 
demonstrate  the  bacilli  of  Koch  in  the  fibrin,  but  found  them  in  the  serous 
layer,  and,  to  a  lesser  extent,  in  the  subserous  zone  of  infiltration.  The 
round-celled  zone  on  the  visceral  side  was  particularly  wide,  vascular,  con- 
tained some  giant-cells,  and  in  some  places  dipped  down  into  the  myocardial 
tissue,  which  was  fatty  in  these  situations.  The  bacilli  occupied  the  same 
regions,  by  preference,  as  in  the  parietal  coat. 

The  extent  and  the  character  of  the  adhesive  inflammation  of  tuberculous 
pericarditis  are  full  of  interest.  Should  the  process  be  sUght,  or  death  occur 
in  the  early  stages  of  the  disease,  or  abundant  exudation  supervene,  adhesions 
are  encountered  which  are  of  little  extent,  are  recent,  delicate,  and  fragile 
in  nature,  easily  torn  through,  and  are  sometimes  in  evidence  only  at  the 
basic  regions  of  the  heart. 

In  cases  of  longer  duration,  in  which  the  tuberculous  process  is  more 
virulent  and  intense,  and  in  those  which  embody  an  almost  distinct  type 
of  adhesive  inflammation,  the  agglutination  of  the  pericardial  surfaces  may 
be  extensive  and  not  rarely  complete — an  actual  symphysis  of  the  layers. 
In  such  an  event  the  surfaces,  even  when  completely  adherent,  can  be 
separated  by  gentle  traction,  as  reported  by  Teissier;  often,  however,  the 
welding  is  absolute,  so  that  isolation  of  the  leaflets,  even  by  careful  dissec- 
tion, is  impossible. 

Symphysis  of  the  pericardium  is  a  termination  of  adhesive  inflammation, 
as  well  as  the  initial  factor  in  pathological  changes  in  the  heart  and  adjacent 
viscera.  In  conditions  of  complete  fusion,  v.'hich  are  those  usually  of  ex- 
tensive plastic  exudate  and  subsequent  fibrosis,  the  heart  is  incased  in  a 
veritable  sheath,  which,  of  necessity,  greatly  interferes  with  its  normal 
functional  activity.  It  is  usual,  therefore,  to  find  the  heart  itself  small, 
atrophied  rather  than  hypertrophied,  although  the  latter  condition  has  been 
observed  in  some  cases  (Boisson,  Boutavant,  Mircouche,  quoted  by  Chappe). 
This  decrease  in  size  must  be  incident  to  two  factors,  namely,  the  dynamic 
limitation  by  the  inhibiting  sheathing  and  the  actual  interference  with  the 
cardiac  nutrition  because  of  involvement  of  the  coronary  arteries,  fibrosis 
and  narrowing  of  these  structures  having  been  frequently  reported.  The 
myocardium  is  frequently  flabby  and  fatty,  and  at  times  is  tuberculous 
contiguous  to  the  pericardial  investment,  but  not  elsewhere. 

Pericardial  symphysis  causes  encroachment  upon  the  lumen  of  the  large 


468  SIXTH    INTERNATIONAL   CONGRESS    ON   TUBERCULOSIS. 

veins,  with  obstructive  congestion  of  the  viscera,  most  notably  seen  in  the 
liver.  When  the  adhesive  type  of  disease  causes  or  accompanies  similar 
changes  in  adjoining  parts,  the  pericardium,  pleurae,  mediastinal  structures, 
glands,  vessels,  and  nerves  may  be  completely  matted  together  in  a  mass 
of  fibrous  tissue — the  mediastinopericarcUtis  of  Kussmaul.  This  agglutina- 
tion may  extend  from  the  diaphragm  to  the  thoracic  apex,  and  from  the 
sternum  in  front  to  the  vertebral  column  behind,  as  was  especially  noted  in 
one  of  Dubard's  cases.  Traction  by  newly  formed  fibrillar  tissues  may  l^e 
responsible  for  dislocation  of  the  heart,  most  frequently  toward  the  right, 
because  of  the  predominating  influence  of  mediastinal  inflammation. 

One  is  struck  by  the  frequency  of  valvular  lesions  in  tuberculous  peri- 
carditis. Vegetations  are  not  rare  upon  the  mitral  and  tricuspid  valves, 
and  Dubard  has  noted  vegetations  of  an  actual  tuberculous  character  within 
the  right  auricle  itself. 

The  effusions  into  the  pericardium  vary  greatly  in  amount,  from  a  few 
cubic  centimeters  to  as  much  as  a  liter  (Roger,  Richardier  and  Teissier, 
Sergent,  Dubard).  In  most  cases  the  fluid  exudate  is  moderate  in  amount, 
does  not  usually  undergo  the  variations  in  quantity  noted  in  rheumatic 
types,  and  differs  from  the  latter  in  frequently  being  hemorrhagic,  a  char- 
acteristic readily  explained  by  the  structure  of  the  vegetations.  With  large 
serous  effusions  one  is  likely  to  encounter  similar  bulky  exudates  in  the 
pleural  and  peritoneal  cavities,  a  group  of  kindred  phenomena  almost  as 
frequent  as  the  concomitant  adhesive  inflammations  of  these  structures. 

Of  especial  importance  from  an  etiological  standpoint  is  the  constant 
adenopathy  of  the  mediastinum.  In  this  locality  the  tuberculous  tracheo- 
bronchial and  peribronchial  glands  may  be  few  and  isolated,  or,  there  may 
be  such  extensive  agglutination  that  the  term  mediastinitis  may  be  fitly 
applied  to  it.  Infection  and  degeneration  of  these  glands  is  the  primary 
macroscopical  focus  of  disease  in  the  majority  of  cases  of  tuberculous  peri- 
carditis, the  atrium  of  the  tonsil,  rhinopharynx,  bronchial  mucosa,  and  the 
intermediation  of  the  cervical  lymph-glands  are  etiological  steps  of  impor- 
tance in  tracing  the  participation  of  the  pericardium  in  the  tuberculous 
process.  In  no  case  reviewed  in  the  literature,  where  examination  of  the 
mediastinal  glands  was  made,  was  evidence  of  tuberculous  inflammation 
lacking. 

Of  next  importance  are  pleural  tuberculosis  and  extension  by  contiguity 
to  the  pericardium.  In  the  literature  examined  the  pleura?  were  almost 
constantly  tainted  by  the  tuberculous  process,  and  the  lungs  without  excep- 
tion. The  initial  lesion  in  the  lungs  frequently  usurps  the  mediastinal 
inflammation  as  the  causative  factor  in  the  pericarditis  of  the  disease  in 
question. 

Autopsy  may  disclose  general  miliary  tuberculosis,  with  involvement  of 


TUBERCULOSIS    OF   THE    PERICARDIUM    IN    CHILDREN. — WALL.  469 

the  spleen,  liver,  kidney,  peritoneum,  and  brain.  The  liver  rarely  escapes, 
and  may  present  features  of  disease  that  are  more  or  less  characteristic 
when  in  association  with  tuberculous  pericarditis,  and  especially  when  this 
process  results  in  symphysis  of  the  leaflets,  Hutinel  describes  a  "foie 
cardio-tuberculeux,"  which  is  large,  passively  congested,  with  fatty  cirrhosis 
and  tuberculous  infiltration.  An  obstructive  cirrhosis  is  the  rule  in  sym- 
physis, although  at  times  the  perihepatic  capsule  bears  the  brunt  of  the 
disease  and  participates  in  the  general  fibrosis. 

In  the  abdominal  cavity  caseation  of  the  retroperitoneal  glands  and 
intestinal  ulceration  have  been  noted — ^the  latter  by  Sergent  and  in  Case  I 
of  my  own. 

Symptomatology  and  Diagnosis. 

We  have  referred  to  the  latency  of  this  affection,  and  would  again  empha- 
size its  quiescence,  even  where  very  extensive  effusion  has  occurred.  But 
here  again  the  frequency  with  which  tuberculosis  of  this  sac  will  be  recog- 
nized must  depend  largely  on  the  skill  of  the  observer,  who  will  undoubtedly 
recognize  tuberculous  pericarditis  in  a  larger  proportion  of  tuberculous 
children  when  he  knows  of  its  frequency,  and  is  able  to  appreciate  its  physical 
signs. 

Aside  from  those  cases  which  are  recognized  only  at  autopsy,  because  of 
their  obscurity  during  life,  there  are  types  of  pericardial  disease  that  draw 
attention  to  the  heart  even  in  cursory  examinations.  In  the  dry  forms, 
without  permanent  adhesion  of  the  leaflets,  the  physical  signs  are  sufficiently 
marked  to  attract  attention  in  many  instances.  The  palpatory  friction  can 
often  be  made  out  and  confirmed  by  the  more  frequent  pericardial  rub, 
which  is  sometimes  soft,  simulating  a  murmur,  and  at  other  times  distinct 
and  characteristic — creaking,  the  bndt  de  cuir  neuj  of  the  French,  and  to  and 
fro,  coincident  with  the  cardiac  cycle.  Sears  points  out  the  necessity  of 
examining  the  back  of  the  chest,  and  reports  an  instance  where  a  murmur, 
very  feeble  in  front,  was  pronounced  just  above  and  inside  the  angle  of  the 
left  scapula  behind. 

In  the  event  of  effusion,  these  physical  signs  gradually  abate  and  are 
replaced  by  others  significant  of  fluid  in  the  sac.  The  elasticity  of  the 
thoracic  wall  in  childhood  may  permit  distinct  bulging  in  cases  of  large 
accumulations  of  fluid,  with  which  is  associated  increase  in  the  cardiac 
dullness,  or  even  flatness,  extending  to  the  left  of  the  nipple  and  to  the 
right  of  the  sternum,  especially  in  the  sternohepatic  angle,  as  indicated  by 
Rotch. 

Weill  has  pointed  out  an  important  sign  which  is  sometimes  present, 
namely,  the  impulse  shock  being  felt  or  seen  to  the  inner  side  of  the  left 
border  of  flatness,  as  determined  by  percussion.     At  times  there  is  a  wave- 


470  SIXTH    INTERNATIONAL   CONGRESS    ON   TUBERCULOSIS. 

like,  undulatory  impulse  in  the  precordial  region,  covering  two  or  three 
interspaces.     Arhythmia,  embryocardia,  and  gallop  rhythm  are  common. 

The  effusion  of  tuberculous  pericarditis  is  often  masked  by  the  presence 
of  fluid  exudates  in  the  pleurae,  especially  the  left,  and  even  after  careful 
examination  in  the  knee-chest  position  one  cannot  speak  with  certainty 
concerning  the  location  of  the  exudate.  The  diminution  of  intensity  and 
distant  character  of  the  valve  sounds  are  observed  in  the  presence  of  large 
effusions. 

Symphysis  of  the  leaflets  may  be  devoid  of  any  physical  signs  of  spec- 
ificity, 5'et  in  long-standing  cases  the  general  picture  may  lead  to  a  correct 
diagnosis,  and  even  to  the  differentiation  of  tuberculous  from  rheumatic 
symphysis.  So  far  as  the  heart  is  concerned,  signs  of  marked  cardiac 
mischief,  with  but  little  enlargement  and  even  diminution  in  size,  retraction 
of  the  apical  region  during  systole,  lowered  arterial  pressure  with  evidences 
of  increased  pressure  in  the  veins,  and  cardiac  crises  may  signify  welding 
of  the  serous  surfaces.  When  obstructive  effects  supervene,  there  is  marked 
enlargement  of  the  liver,  which  is  smooth  and  painless;  ascites  develops, 
the  abdominal  veins  become  prominent,  and  enlargement  of  the  spleen, 
with  insufficiency  of  the  kidney  and  albuminuria,  occur  secondarily. 

The  general  symptoms  are  progressive  asthenia,  precordial  pain,  dyspnea, 
which  may  be  intense  and  compel  a  sitting  attitude,  and  fever,  which  is 
usually  of  the  irregular  type,  often  accompanied  with  profuse  sweats. 
Concomitant  tuberculous  lesions  elsewhere  may  be  responsible  for  the  tem- 
perature. 

The  pulse  is  so  frequent  as  often  to  attract  attention  to  the  heart,  and 
with  the  further  suspicious  presence  of  dyspnea,  the  observer  should  be  able 
to  find  the  signs  of  tuberculous  pericarditis.  The  pulsus  paradoxus  is  often 
encountered. 

Brown  points  out  that  when  edema  of  the  face  comes  on  rapidly  in  peri- 
cardial effusions,  the  prognosis  is  very  grave.  Death  not  infrequently 
occurs  from  disease  of  other  organs,  especially  of  the  lungs  and  meninges. 

Prevention  and  Treatment. 
Treatment  is,  in  reality,  reduced  to  prevention,  and  this  is  to  consist 
of  that  especial  care  of  the  growing  child  in  health  and  in  disease,  by  which 
his  resistance  to  tuberculous  infection  is  heightened,  and  his  ability  to  recover, 
when  infected,  is  enhanced.  The  encouraging  results  of  the  open-air 
treatment  of  tuberculous  lesions  elsewhere  than  in  the  lungs,  especially  of 
gland  tuberculosis,  as  practised  by  Halstead  and  others,  will  save  the  life 
of  many  of  those  who  harbor  the  initial  focus  capable  of  giving  rise  to  the 
disease  in  question.  Should  latent  tuberculosis  be  proved  or  suspected, 
should  the  refined  diagnostic  technic  of  Calmette,  Moro,  or  von  Pirquet 


TUBERCULOSIS   OF   THE    PERICARDIUM   IN   CHILDREN. — WALL.  471 

be  further  developed,  many  little  ones  would  be  saved,  through  preventive 
measures,  from  death  by  tuberculous  pericarditis  and  meningitis,  so  often 
the  fruit  of  seed  sown  and  propagated  in  the  mediastinal  glands. 

The  care  of  convalescent  children  should  engage  our  earnest  attention, 
for  too  often  these  little  ones  are  sent  from  our  hospitals  to  unsanitary  homes, 
placed  amid  vile  surroundings,  where  they  may,  in  their  debility,  prove  an 
easy  prey  to  the  tuberculous  poison. 

There  are  on  record  cases  in  adult  life  that  have  been  treated  by  aspira- 
tion, sometimes  frequently  repeated,  with  apparent  recovery.*  For  pur- 
poses of  record,  the  following  two  observations  of  tuberculosis  of  the  peri- 
cardium are  reported : 

Case  I. — A  female  infant  of  two  months  was  admitted  to  the  Foundlings' 
Hospital.  Family  and  antecedent  history  unknown.  From  the  date  of 
its  admission  it  had  an  exhausting  chronic  intestinal  indigestion,  and  about 
six  weeks  before  death  there  were  cough  and  fever  and,  for  two  weeks, 
difficulty  in  breathing.  Examination  revealed  consolidation  of  the  left 
upper  lobe  and  dullness  down  to  the  nipple  line,  where  it  became  continuous 
with  the  cardiac  dullness.     Von  Pirquet's  test  was  positive. 

On  autopsy  there  were  found  tuberculous  degeneration  of  the  mesenteric 
and  broncliial  glands,  some  tubercles  in  the  spleen,  liver,  and  lungs,  the  left 
lung  showing  in  its  upper  portion  consolidation  with  small  cavity  formation. 
There  were  two  large  ulcers  in  the  jejunum.  The  pericardial  sac  contained 
about  100  c.c.  of  yellowish  fluid.  The  leaflets  were  thickened,  and  minute 
tubercles  were  scattered  upon  their  surfaces. 

Case  II. — A  boy  of  five  was  admitted  to  the  Cliildren's  Hospital  May  22, 
1908.  His  previous  history  showed  that  he  had  had  measles  two  years  ago, 
followed  by  pertussis.  He  was  admitted  with  cough,  abdominal  pain,  and 
asthenia.  Examination  revealed  dullness  on  the  right  side  anteriorly,  with 
bronchial  breathing  and  a  few  rales.  The  left  side  behind  showed  some  dry 
rales. 

There  were  bulging  of  the  precordium  and  increase  in  the  extent  of  cardiac 
dullness,  but  no  murmurs  nor  rubs.  The  apex-beat  could  be  felt  and  was 
displaced  outwardly. 

June  8th :  Persistent  cough  and  complaint  of  pain  below  the  precordium. 
Pulse  158,  thready  and  small.     Dyspnea  is  now  a  prominent  symptom. 

June  15th:  Labored  breathing,  general  condition  unchanged. 

June  21st:  Dyspnea  intense,  requiring  a  constant  sitting  posture. 

June  28th:  Progressive  exacerbation  of  symptoms;  marked  bronchial 
breathing  over  lower  part  of  right  lung;  great  increase  in  heart  dullness; 
enfeeblement  of  the  valve-sounds;  edema  of  the  face.  Death  occurred 
July  2d. 

Autopsy  revealed  extensive  tuberculous  lesions  in  the  lungs,  liver,  and 
spleen.  The  mediastinal  glands,  especially  those  in  proximity  to  the 
roots  of  the  great  vessels,  were  caseous,  matted  together  in  a  mass  of  adhe- 
sions, and  at  this  point  showed  the  intensity  of  the  tuberculous  infection. 
The  pericardium  was  enormously  distended  with  fluid,  was  thickened  and 

*  Sabin,  Amer.  Med.,  Phila.,  1902. 


472  SIXTH    INTERNATIO-XAL    CONGRESS    ON    TUBERCULOSIS. 

infiltrated  to  a  degree  about  its  insertion  around  the  great  vessels,  and 
presented  scattered  tubercles  upon  the  serosa?. 

In  tliis  child  the  clinical  disturbances  incident  to  the  tuljerculous  peri- 
carditis were  overwhelmingl}^  predominant,  even  in  the  presence  of  rather 
extensive  disease  of  the  lungs. 

BIBLIOGRAPHY. 

Ashby:     Brit.  Med.  Jour.,  London,  1891,  2,  1208. 

Aviragnet:     These  de  Par.,  1892. 

Batte:     Pediatrics,  New  York,  1901,  328. 

Baumel  and  Abadie:     Montpellier  Med.,  1901. 

Brackmann:     "Ueber  tub.  Perikard.  bie  Kind.,"  Gottingen,  1888. 

Brown:     St.  Barth.  Hosp.  Rep.,  London,  1906.  xli,  115. 

Chappe:     These  de  Par.,  1903  (27  cases  and  extensive  bibliography). 

Dubard:     These  de  Pelthier. 

Hudelo:     Bull.  Soc.  Anat.  de  Par.,  1888,  bciii,  1024. 

Hutinel:     Rev.  des  Mai.  de  I'enfance,  1893,  1894. 

Longues:     Bull.  Soc.  Anat.  de  Par.,  1889,  Lxiv,  Gil. 

Morison:     Lancet,  London,  1906,  11,  209. 

Netter:     Bull.  Soc.  Anat.  de  Par.,  1889. 

Osier:     Amer.  Jour.  Med.  Sci.,  1893. 

Peyre:     These  de  Par.,  1893. 

Ramsey:     St.  Paul  Med.  Jour.,  1903,  v,  675. 

Schmneker:     Wien.  med.  Woch.,  1883. 

Sears:     Bost.  Med.  and  Surg.  Jour.,  1897,  cxxxvi,  383. 

Sequiera:     Trans.  Path.  Soc.  London,  1896,  xlviii,  41. 

Sergent:     Soc.  Anat.  de  Par.,  1893. 

Still:     Pediatrics,  New  York,  1901,  xii,  332. 

Thayer:     Maryland  Med.  Jour.,  1903,  xlvi,  123. 

Bury:     Brit.  Med.  Jour.,  December,  1891. 

Richardier  and  Teissier:     Annal.  de  Med.  et  Surg.  Infant.,  Paris,  1904. 


DES  ALBUMINURIES  INTERMITTENTES  DE  L'ENFANCE 

CONSIDEREES  DANS  LEURS  RELATIONS  AVEC 

L'HEREDITE  TUBERCULEUSE. 

Par  le  Docteur  J.  Teissier, 

Professeur  de  Clinique  mc^dicale  k  TUniversit^  de  Lyon 


L'h^r^dite  tuberculeuse  peut  frapper  le  rein  chez  I'enfant  ou  chez 
I'adulte  suivant  una  triple  modalite: 

1.  Chez  certains  sujets,  il  existe  une  albuminurie  plus  ou  moins  abon- 
dante,  de  preference  intermittente;  pouvant  affecter  un  des  cycles  classiques 
connus,  mais  qui,  disparaissant  a  mesure  que  les  localisations  pulmonaires 
s'etablissent  ou  se  generalisent,  merite  le  nom  d'albuminurie  pr^tubercu- 
leuse. 

Cette  albuminurie  n'implique  pas  necessairement  I'existence  d'une 
tuberculose  renale.  Elle  nous  semble,  au  contraire,  repondre  a  une  origine 
toxinique  et  relever  de  la  bacteriolyse  qui  traduit  les  moyens  de  defense 
spontanee  de  Torganisme.  Lorsque  cette  destruction  spontanee  cesse  de  se 
produire,  la  tuberculose  evolue  et  ralbuminurie  cesse. 

2.  II  existe  d'autre  part,  une  tuberculose  renale  primitive  isolee,  ou 
associee  k  des  determinations  vesicales  de  meme  nature  et  dont  revolution 
classique  est  bien  connue. 

3.  Enfin,  dans  une  troisieme  serie  de  faits — serie  de  beaucoup  la  plus 
nombreuse — le  rein  est  impressionne  d'une  fagon  tout  particulierement 
interessante  et  qu'une  longue  suite  de  faits  similaires  nous  a  permis  de 
determiner  avec  un  degre  de  quasi  certitude:  le  rein  apres  avoir  subi  Taction 
de  la  toxine  tuberculeuse  transmise  par  voie  ancestrale,  a  r6agi  lentement, 
sourdement,  et  il  s'est  constitu6  ainsi  un  leger  degrc  de  nephrite  latente, 
qui  a  abouti  5;  une  impermeabilite  tres-relative,  laquelle  se  traduit  par  une 
diminution  legere  de  la  diurese  mol^culaire  totale,  une  elevation  du  coeffi- 
cient -V  de  Korani,  une  surelevation  Idgere  aussi,  de  lapression  arterielle;  une 
albuminurie  d'intensite  moyenne,  gen^ralement  intermittente,  h  type  matinal 
ou  franchement  orthostatique,  et  enfin,  comme  signature  meme  de  I'ori- 
gine  tuber culineuse  des  accidents,  une  s^ro-r6action  d'Arloing-Courmont 
extremement  nette,  et  d^passant  souvent  I'agglutination  au  yV°-  Ces 
cas,  qui  dans  nos  statistiques  d6passent  34  pour  cent  des  faits  d'albuminurie 

473 


474  SIXTH   INTERNATIONAL  CONGRESS   ON   TUBERCULOSIS. 

intermittente  des  jeunes  sujets,  n'evoluent  pas  vers  la  tuberculose  con- 
firmee. Pour  cette  raison,  lis  nous  semblent  meriter  et  justifier  la  denomina- 
tion d'albuminurie  paratuberculeuse — et  pour  plusieurs  d'entre  eux,  ren- 
trer  dans  le  cadre  de  ces  immunisations  spontanees  sur  lesquelles  le  professeur 
Calmette  attire  a  I'heure  actuelle  toute  I'attention. 

Les  propositions  ci-dessus  qui  peuvent  servir  a  la  fois  de  premisses  et  de 
conclusions  a  notre  communication,  m^riteraient  chacune  des  developpe- 
ments  importants.  Je  n'insisterai  pourtant  que  sur  la  troisieme  parce  que 
les  faits  qui  s'y  rattachent  sont  les  moins  connus  et  qu'ils  sont  susceptibles 
au  point  de  vue  pratique  de  considerations  tres  dignes  d'int^ret. 

C'est  d'abord  leur  tres  grande  frequence,  puisque  plus  du  tiers  des  al- 
buminuries  de  I'enfance  reconnaissent  une  semblable  etiologie. 

C'est  ensuite  la  discordance  souvent  frappante  entre  le  bon  aspect  general 
du  patient,  parfois  d'apparence  robuste,  sans  manifestation  morl^ide- notable 
sur  aucun  viscere,  qui  presente  une  pression  arterielle  plutot  forte  (de  16  a 
18  cm.)  fait  absolument  exceptionnel  dans  la  tuberculose  ou  Ton  releve  en 
general  une  pression  radiale  au-dessous  de  13  cm.  et  qui  n'a  d' autre  stig- 
mate  humoral  permettant  d'affirmer  I'impregnation  toxinique  que  la  pro- 
priete  extremement  marquee  du  serum  sanguin  a  agglutiner  les  cultures 
homogenes  du  bacille  de  Koch,  preparees  par  notre  eminent  collegue,  le 
Professeur  Arloing. 

Mais  alors,  si  Ton  fouille  les  antecedents  familiaux  de  pareils  sujets,  on 
arrive  toujours  a  deceler  chez  eux  une  heredite  tuberculeuse  plus  ou  moins 
chargee  et  contre  laquelle  ils  se  sont  premunis  par  une  vie  bien  reglee,  une 
hygiene  excellente  ou  une  resistance  individuelle  tres  remarquable. 

J'observe  en  ce  moment  la  troisieme  generation  d'une  fam-ille  de  tuber- 
culeux  ou  deux  enfants  sur  quatre,  issus  d'un  pere  tuberculeux  dont  la  mere 
fut  elle-meme  tuberculeuse  et  qui,  a  un  moment  contamina  sa  femme, 
eurent  de  1' albuminuric  intermittente,  manifestation  certaine  de  I'influence 
constitutionnelle  familiale  (et  qui  sont  gueris  d'ailleurs)  et  dans  la  propre 
descendance  desquels,  je  trouve  deux  enfants  albuminuriques  intermittents  et 
quatre  d'entre  eux  avec  une  sero-reaction  tuberculeuse  tres  positive.  Dans 
toute  cette  famille,  comportant  plus  de  15  membres,  il  n'y  a  aucun  sujet  mani- 
festement  infecte  et  la  majorite  presente  la  reaction  d' agglutination  d'Arloing- 
Courmont  tres  developpee.  Je  pourrais  citcr  de  nombreux  faits  analogues 
et  qui  sont  presque  tons  monies  sur  ce  meme  type:  des  grands-parents  encore 
vivants  ayant  eu  des  manifestations  tuberculeuses  certaines  mais  aujourd'hui 
eteintes,  ou  bien  morts  jeunes  de  tuberculose  souvent  rapide;  des  parents,  la 
mere  en  general,  parfois  et  assez  frequemment  des  oncles  ou  des  tantes, 
avec  des  tuberculoses  localisees  ou  attenuees  (tuberculose  vesicale,  testicule 
tuberculeux,  lupus.  .  .  .)  et  qui  ont  eux-memes  de  I'albuminurie  intermit- 
tente mais  avec  une  sero-reaction  tres  positive.     Ceux-la  guerissent  au  bout 


ALBUMINURIES  IXTERMITTENTES  DE  l'eNFANCE. — TEISSIER.  475 

d'un  certain  nombre  d'annees,  parce  qu'ils  ont  regu  (cela  me  semble  tres 
vraisemblable)  avec  les  toxines  qui  ont  touche  leur  rein,  les  antitoxines  qui 
les  ont  preserves  ou  immunises. 

C'est  ce  qui  nous  fait  admettre  cette  conception  surement  tres  souteii- 
able,  que  I'heredite  tuberculeuse  peut  n'avoir  influence  la  descendance  que 
sous  forme  d' impregnation  toxinique. 

J'ai  pu  me  rendre  compte  cle  cette  impregnation  de  tous  les  tissus  et  dc 
toutes  les  humeurs  chez  une  ancienne  malade  de  mon  service,  malade  que 
nombre  de  mes  collegues  ont  examinee— la  jeime  jNIarie  M .  .  .  . ,  atteinte  do 
dextrocardie  avec  double  retrecissement  mitral  et  pulmonaire  et  qui,  a 
plusieurs  reprises,  presenta  une  serie  de  manifestations  pleuro-pulmonaires, 
cerebrales,  meningeales  et  peritoneales  que  chaque  fois  on  eut  tendance  a 
imputer  a  la  tuberculose.  !Mais  toutes  les  humeurs,  vingt  fois  examinees, 
ne  presentent  jamais  un  seul  bacille,  mais  toujours  une  sero-reaction  posi- 
tive, qui  atteignait  souvent  im  taux  inaccoutume,  et  chaque  fois  la  malade 
sortait  victorieuse  de  ses  crises.  Elle  finit  pourtant  par  succomber  a  une  at- 
taque  d'asystolie.  Or  les  recherches  necroscopiques  faites  avec  la  plus  ex- 
treme attention  ne  permirent  pas  de  retrouver  la  trace  de  la  moindre  granu- 
lation tuberculeuse. 

L'existence  des  faits  en  eux-memes  ne  parait  done  pas  contestable:  le 
grand  interet  clinique  consiste  dans  la  faculte  de  les  reconnaitre  et  de  les  isoler 
des  cas  similaires. 

Or  chez  les  enfants,  k  moins  des  faits  de  nephrite  residuale  post-scarla^ 
tineuse,  ourlienne  ou  tj^liique  qui  peuvent  entrainer  un  certain  degre 
d'impermeabilite  renale  et  retentir  sur  la  circulation  centrale  et  augmenter 
le  degre  de  la  tension  arterielle,  les  albuminuries  d'ordre  fonctionnel  (cyc- 
Uque,  digestive,  orthostatique  pure  ou  associee)  se  caracterisent  par  une 
grosse  elevation  cle  la  diurese  moleculaire,  I'abaissement  du  coefficient  -^ 
une  diminution  notable  de  la  pression  arterielle,  souvent  la  mobilite  d'un 
rein  ou  des  deux  reins  comme  dans  les  faits  de  Sutherland.  Enfin  la  faculty 
d' agglutination  du  serum  sanguin  vis-a-vis  des  cultures  de  bacilles  tubercu- 
leux  est  negative  ou  a  peine  ebauchee. 

Chez  les  sujets  toxinises,  au  contraire,  qui  presentent  la  sero-r6action 
tres  d6veloppee,  la  diurese  moleculaire  reste  au-dessous  de  3.000  (chiffre 
faible  pour  des  adolescents)  et  le  coefficient  .  varie  entre  1,60  et  1,80. 
Done  legere  impermeabilite,  mais  impermealjilite  certaine.  Le  16ger  degr^ 
d'hypertension  relative  qui  raccompagne  oscille  de  14  k  17-18,  chiffre  4videm- 
ment  rarement  note  dans  les  albuminuries  intermittentes  communes  de 
I'enfance  generalement  accompagn6cs  de  tendance  depressive. 

Nous  avions  d6}k  en  1905,  au  Congr^s  international  de  la  tuberculose 
a  Paris,  et  plus  tard,  a  Genes,  au  Congrds  de  M^decine  interne  tenu  en  oc- 


476  SIXTH    INTERNATIONAL   CONGRESS    ON   TUBERCULOSIS. 

tobre  1905,  insiste  sur  quelques  unes  des  ces  distinctions  fondamentales. 
Les  faits  que  nous  avons  recueillis  depuis  n'ont  fait  que  confirmer  notre 
opinion.  Pas  un  de  nos  petits  malades  n'a  eu  de  manifestations  meme 
suspectes  de  tuberculose,  et  nous  sommes  disposes  a  croire  que  la  plupart 
d'entre  eux  marche  vers  I'immunisation  temporaire  ou  definitive.  C'est 
une  conception  que  nous  avions  timidement  formulee  au  Congrcs  de  Paris 
et  sur  laquelle  nous  insistons  avec  plus  d'assurance  aujourd'hui. 

Ce  que  nous  venons  de  dire  pour  le  rein,  nous  pourrions  le  repeter  sans 
doute  pour  une  serie  d'autres  manifestations  ancestrales  d'ordre  toxinique 
(comme  le  retrecissement  mitral  pur,  certains  cas  d'entero-colite,  etc.) 
qui  pourraient  constitiuer  le  groupe  des  manifestations  paratuberculeuses. 

L'avenir  se  chargera  de  demontrer  le  bien-fonde  de  pareilles  assertions 
qui  nous  semblant  d'autant  plus  soutenables  que  nombre  de  faits  qui  nous 
interessent  sont  tout  a  fait  assimilables  avec  ceux  sur  lesquels  M.  Calmette  se 
fonde  pour  defendre  I'idee  de  Fimmunisation  spontanee  a  la  suite  des  in- 
fections tuberculeuses  legeres  ayant  frappe  pendant  I'enfance  I'appareil 
entero-mesenterique  ou  les  glandes  lymphatiques  du  groupe  tracheo-bron- 
chique. 

Un  de  nos  petits  malades  conserve  de  I'albumine  intermittente  cyclique 
pendant  quatre  ans:  il  guerit,  mais  a  I'albuminurie  disparue,  succede  une 
poussee  de  mesenterite  suspecte.  Repos,  sejour  a  la  mer,  suspension  des 
etudes.  II  guerit  encore.  C'est  aujourd'hui  un  officier  distingue,  qui  a  fait 
des  campagnes  lointaines :  ces  accidents  remontent  a  plus  de  vingt  ans  et  il 
est  en  parfaite  sante.  Ne  peut-on  pas  le  considerer  comme  spontan^ment 
immunis? 

Assurement  la  preuve  experimentale  ne  peut  en  etre  fournie.     Mais  au 
nom  de  la  Clinique,  on  est  autorise  a  la  considerer  comme  infiniment  prob- 
able. 
Travaux  du  Professeur  J.  Teissier  (de  Lyon)  relatifs  aux  nephrites  et  aux  alburninuries. 

1.  "Albuminurie  intermittente   cyclique    (maladie   de  Pa vy -Teissier),"   Association 

francaise  pour  I'avancement  des  Sciences,  Grenoble,   1884.  Cf.  aussi  Bulletin 
medical,  1884. 

2.  "Albuminurie  pr^tuberculeuse,"  CongrSs  de  medecine  interne,  Lyon,  1894. 

3.  "Albuminurie  hepatogene,"  Le^on  clinique  in  Semaine  medicale,  1899. 
4     "Albuminurie  orthostatique,"  Le9on  clinique  in  Semaine  m6dicale,  1899. 

5.  "Nephrites  paludeennes,"  Congres  international  de  M6decine,  Le  Caire,  1902. 

6.  "Classification  et  valeur  pathogenique  des  albuminuries  orthostatiques,"  Revue 

de  Medecine,  avril,  1905. 

7 .  "  Les  nephrites  residuales , ' '  Legon  clinique  Bulletin  medical,  1904. 

8.  "Traitement  des  nephrites  et  opotherapie,"  Bulletin  mddical,  1904. 

9.  "Albuminurie  et  h^r^dit^  tuberculeuse,"  Congres  de  la  Tuberculose,  Paris,  1905. 

10.  "Albuminiiries  aceto-solubles,"  Province  medicale,  1906. 

11.  "Les  Albuminuries  curables,"  Un  volume  de  la  collection  des  Actualites  m^dicales, 

J.  B.  Baiin^re,  editeur,  1900  and  1907. 


ALBUMINURIES  INTERMITTENTES  DE  l'eNFAxXCE. — TEISSIER.  477 

Intermittierende  Albuminuric  in  der  Kindheit  in  ihren  Beziehungen  zu 
erblicher  Tuberkulose  betrachtet. — (Teissier.) 

Erbliche  Tuberkulose  kann  die  Nieren  des  Kindes  oder  des  Erwachsenen 
auf  eine  von  drci  Arten  befallen: 

1.  Gewisse  Individuen  zeigen  eine  mehr  oder  weniger  reichliche  Albu- 
minurie,  welche  vorzugsweise  interniittierend  ist  imd  einen  der  wolilbe- 
kannten  klassischen  Kreise  affizieren  mag;  sie  verschwindet  aber,  sobald 
die  Beschrankung  auf  die  Lungen  hergestellt  ist  oder  gibt  Anlass  zu  allge- 
meinen  \'erletzungen  und  mag  daher  als  prdtuberkulose  Albuminurie 
bezeichnet  werden. 

Diese  Form  von  Albuminurie  zeigt  noch  nicht  das  Vorhandensein  von 
Nierentuberkulose  an,  sondern  scheint  im  Gegenteil  einen  toxischen  Ur- 
sprung  zu  haben  und  ahnelt  der  Bacteriolyse,  welche  ein  Ausdruck  der 
spontanen  Verteidigungsanstrengungen  des  Organismus  ist.  Sobald  als 
diese  spontane  Zerstorung  aufhort,  entwickelt  sich  Tuberkulose  und  die 
Albuminurie  kommt  zum  Stillstande. 

2.  Die  zweite  Form  der  Tuberkulose  ist  durch  den  tjbersetzer  aus- 
gestrichen  worden. 

Endlich  haben  wir  eine  dritte  Serie  von  Fallen,  die  viel  zalilreicher 
sind.  Die  Niere  ist  in  einer  eigentiimlichen  Weise  affiziert,  cUe  wir  durch 
eine  lange  Serie  ahnlicher  Beobachtungen  beinahe  mit  Sicherheit  bestimmen 
konnten.  Die  Niere  reagirt  sehr  langsam  und  schw^erfaUig  auf  die  Wirkung 
des  tuber kulosen  Toxins,  das  durch  die  Eltern  iibertragen  ist,  und  es  ist  ein 
leichter  Grad  von  latenter  Nephritis  hervorgerufen,  welcher  in  einer  sehr 
relativen  Unzuverlassigkeit  resultirt  und  sich  durch  eine  massige  Vermin- 
derung  der  totalen  Aloleculardiurese  beruhigt,  und  durch  ein  Wachsen  in 
dem  Coefhcienten  und  auch  in  einer  leichten  Steigerung  des  Blutdruckes. 
Eine  massig  schwere  Albuminurie  ist  fiir  gewohnlich  interniittierend,  ent- 
weder  vom  Morgentypus  oder  einfach  orthostatisch  (wahrend  der  tatigen 
Tagesstunden  anwesend),  und  endlich  als  ein  Zeichen  ihres  tuberkulosen 
Ursprunges  eine  wohl  entwickelte — d'Arloing-Courmont — Serumreaction, 
die  oft  Y^  iiberschreitet.  Diese  Falle,  welche  mehr  als  34  Prozent  unserer 
Statistik  der  intermittierenden  Albuminurie  bei  jungen  Individuen  aus- 
machen,  gehen  nicht  in  wirkhche  Tuberkulose  iiber.  Deshalb  scheinen  sie 
den  Ausdruck  " paratuberkuluse  Albuminurie"  zu  rechtfertigen  und  vicle 
dieser  Fiille  gehoren  zur  Kategorie  spontaner  Immunisierung,  auf  welche 
Professor  Courmont  kiirzlich  die  Aufmerksamkeit  gelenkt  hat. 


Intermittent   Albuminuria   of   Childhood   Considered   in   its  Relation  to 
Hereditary  Tuberculosis. — (Teissier.) 

Hereditary  tuberculosis  may  attack  the  kidney  in  the  child  or  in  the 
adult  in  one  of  two  ways : 


478  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

1.  Certain  individuals  present  a  more  or  less  abundant  albuminuria, 
which  is  usually  intermittent,  and  which  may  affect  one  of  the  well-known 
classical  cycles;  but  it  disappears  as  the  pulmonary  localization  becomes 
established,  or  gives  rise  to  general  lesions,  and  may,  therefore,  be  termed 
pretuberculous  albuminuria. 

This  form  of  albuminuria  does  not  necessarily  imply  the  existence  of 
renal  tuberculosis,  but,  on  the  contrary,  seems  to  have  a  toxic  origin,  and 
resembles  the  bacteriolysis  which  is  an  expression  of  the  spontaneous  de- 
fensive forces  of  the  organism.  As  soon  as  this  spontaneous  destruction 
ceases,  tuberculosis  develops  and  the  albuminuria  disappears. 

2.  Finally,  we  have  a  second  series  of  cases,  which  are  much  more  numer- 
ous. The  kidney  is  affected  in  a  peculiar  manner,  which  we  have  been  able, 
by  a  long  series  of  simila/'  observations,  to  determine  almost  with  certainty; 
the  kidney  reacts  very  slowly  and  sluggishly  to  the  action  of  the  tuber- 
culous toxin  transmitted  by  the  parent,  and  a  slight  degree  of  latent  nephri- 
tis is  produced,  which  results  in  a  very  relative  impermeability,  relieving 
itself  in  a  moderate  diminution  of  the  total  molecular  diuresis,  an  increase 
in  the  coefficient  of  Koranyi,  and  also  in  a  slight  elevation  of  the  blood-pres- 
sure; a  moderately  severe  albuminuria,  usually  intermittent;  either  of  the 
matutinal  (morning)  type,  or  frankly  orthostatic  (present  during  the  active 
hours  of  the  day) ;  and,  finally, — as  the  hall-mark  of  its  tuberculous  origin, — 
a  well  defined  Arloing-Courmont  serum-reaction,  often  exceeding  jVth. 
These  cases,  which  make  up  more  than  34  per  cent,  of  our  statistics  of  in- 
termittent albuminuria  in  young  subjects,  do  not  eventuate  in  actual  tuber- 
culosis. For  this  reason  they  seem  to  justify  the  term  paratuberculous 
albuminuria,  and  many  of  these  cases  belong  to  the  category  of  spontaneous 
immunization. 


SECTION   IV. 

Tuberculosis  in  Children — Etiology,  Prevention, 
and  Treatment  [Continued). 


THIRD  DAY.     MORNING  SESSION. 

Wednesday,  September  30,  1908. 

THE  CHILDREN  OF  TUBERCULOUS  PARENTS.      FAMILY  ASSOCIA- 
TION.    HUMAN  CONTAGION  IN  INFANTILE  TUBERCULOSIS. 


The  President,  Dr.  Jacobi,  called  the  Section  to  order  at  ten  o'clock. 


CHILDREN  OF  THE  TUBERCULOUS. 

By  Theodore  B.  Sachs,  M.D., 

Chicago. 


In  presenting  his  theory  of  the  gradually  accumulating  opportunities  for 
infection  with  the  advance  of  age,  as  an  explanation  of  the  varying  frequency 
of  tuberculosis  at  different  periods  of  human  life,  Cornet  finds  substantiation 
in  the  clinical,  mortality,  and  autopsy  statistics. 

The  fact  of  the  more  frequent  occurrence  of  fully  developed  tuberculous 
lesions  in  adult  life,  as  compared  with  infancy  and  childhood,  is  admitted  by 
the  adherents  of  the  hereditary  theory  of  tuberculosis,  which  assumes  a 
prenatal  infection,  followed  by  innocuousness  of  the  infecting  agent  during 
the  first  year  of  life. 

While  the  paucity  of  authenticated  cases  of  congenital  tuberculosis — ^in 
all  about  20 — makes  the  conception  of  hereditary  transmission  of  the  disease 
itself  untenable,  the  idea  of  prolonged  latency  of  the  tubercle  bacillus  does 
not  conform  with  the  present  knowledge  of  the  germ,  allowing  it  in  its  usual 
form  but  a  limited  cycle  of  existence  under  the  most  favorable  conditions. 

The  significance  of  the  factor  of  hereditary  predisposition,  in  the  sense 
of  a  "receptive  soil,"  is  accepted  to  a  certain  extent  even  by  the  most  ardent 
contagionists,  but  the  degree  of  its  influence  in  the  development  of  individ- 

479 


480  SIXTH   INTERNATIONAL   CONGRESS    ON   TUBERCULOSIS. 

ual  cases  of  tuberculosis  is  still  undefined,  neither  by  the  accumulated  clini- 
cal nor  laboratory  investigation. 

With  the  assumption  of  the  contagion  theory  of  tuberculosis,  ascribing 
the  origin  of  every  individual  case  to  postnatal  infection,  at  times  of  bovine, 
but  generally  of  human  source,  numerous  problems  in  connection  with  the 
evolution  of  the  disease  still  remain  unsolved,  and  of  these,  the  connection 
between  infection  in  infancy  and  childhood  and  the  development  of  tuber- 
culosis in  later  hfe  is  a  problem  of  greatest  importance  in  the  proper  concep- 
tion of  the  disease  and  formulation  of  effective  measures  for  its  eradication. 

The  solution  must  necessarily  lie  either  in  the  assumption,  by  the  tuber- 
cular germ,  of  a  certain  form  in  which  it  may  remain  inactive  for  a  prolonged 
period  of  time,  or  in  a  specific  hyper-susceptibiUty  imparted  to  the  tissues 
by  previous  infection. 

These  and  various  other  problems  belong  to  the  realm  of  laboratory  and 
experimental  research,  out  of  which  most  of  the  light  must  come  to  explain 
the  obscure  phenomena  of  the  most  wide-spread  disease  of  modern  times. 

The  present  investigation  was  undertaken  with  the  object  of  determining 
the  frequency  of  recognizable  tuberculosis  in  children  exposed  to  infection 
in  surroundings  most  favorable  to  transmission  of  the  disease.  With  this  in 
view,  146  families,  with  one  or  both  parents  known  to  be  tuberculous,  were 
selected  from  the  records  of  the  Chicago  Tuberculosis  Institute,  the 
Visiting  Nurse  Association,  and  my  private  practice. 

Classification  of  the  Parents. — The  parents  were  classified  as  follows : 

Fathers.  Mothers. 

Tuberculous 32  58 

Dead  from  tuberculosis 43  22 

Non-tuberculous 71  66 

In  7  families  both  parents  were  tuberculous.  Fifty-eight  per  cent,  of  all 
deaths  from  tuberculosis  among  parents  occurred  within  one  year  preceding 
the  investigation;  79  per  cent,  within  two  years.  The  families  were  of 
the  average  laboring  class,  living  in  the  poorer  districts  of  the  city,  and 
in  most  cases  impoverished  by  the  protracted  illness  of  father  or  mother. 

Ages  of  the  Children. — ^Total  number  of  children,  479:  19  under  one 
year  of  age  (15  examined);  62  between  one  and  five  years  (48  examined);  105 
between  five  and  ten  (91  examined);  108  between  ten  and  fifteen  (81  exam- 
ined); 86  between  fifteen  and  twenty  (45  examined),  and  99  above  twenty 
(of  the  42  examined,  39  were  between  twenty  and  thirty  years  of  age). 

Ninety  per  cent,  of  the  examined  children  were  breast-fed. 

Mortality. — Up  to  the  time  of  the  investigation  131  deaths  occurred 
in  these  146  families.  Eighty  per  cent,  of  the  entire  mortality  was  in  children 
under  five  years  of  age  (52  per  cent,  in  the  first  year,  28  per  cent,  between  one 
and  five  years).     Only  10  per  cent,  of  deaths  in  the  first  five  years  of  life 


CHILDREN   OF  THE   TUBERCULOUS. — SACHS. 


481 


were  ascribed  to  tuberculosis;  25  per  cent,  to  intestinal  ailments,  and  35 
per  cent,  to  pertussis,  measles,  and  pneumonia,  which  diseases  frequently 
conceal  tuberculosis  in  the  mortality  statistics. 

Eleven  deaths  were  among  children  between  five  and  fifteen  years  (3  due 
to  tuberculosis);  15  deaths  between  fifteen  and  thirty  years  (11  due  to  tuber- 
culosis). 

Manifestations  of  Tuberculous  Infection  in  Children  at  Various 

Ages. 

The  manifestations  of  tuberculous  infection,  at  various  ages,  as  revealed 
by  symptoms  and  physical  signs,  were  as  follows : 

1.  General  Condition.  Habitus  Phthisicus. — The  'parentage  of 
15  children  under  one  year  of  age  (youngest  three  months  old)  included  10 
tuberculous  mothers  and  5  tuberculous  fathers.  Disease  far  advanced  in 
3  mothers  and  5  fathers.  Eleven  children  breast-fed.  General  develop- 
ment of  all  normal,  with  the  exception  of  two,  who  had  slight  flattening  of 
anterior  aspect  of  the  chest.  Weight  normal  or  above  normal  in  10;  slight 
deficiency  in  4;  emaciation  in  one  (tuberculous  meningitis).  Characteristic 
features  of  habitus  phthisicus  absent. 

With  the  advance  of  age,  from  infancy  to  adult  life,  the  stigmata  of  the 
phthisical  type  grow  more  pronounced  and  are  observed  in  a  larger  propor- 
tion of  cases,  as  shown  in  the  following  table: 


Habitus  phthisicus 


Under 
1  Year. 

1   TO  5 

Years. 

5  TO  10 
Years. 

10  TO  15 
Years. 

15  TO  20 
Years. 

6 

6 
per  cent. 

7 
per  cent. 

16 
per  cent. 

16 
per  cent. 

Above  20 
Years. 


21 
per  cent. 


Under  this  heading  were  grouped  children  presenting  the  combination  of 
narrow  chest  (in  anteroposterior  or  both  diameters),  long  neck  and  ex- 
tremities, winged  scapulae,  etc. 

Single  deviations  from  the  normal  type  of  chest  were  observed  with  the 
following  frequency: 


1  to  5 
Years. 

5  to  10 
Years. 

10  TO  15 
Years. 

15  TO  20 
Years. 

Above  20 
Years. 

Flattening   of   the   anterior  aspect 
of   the  chest  and  narrow  antero- 
posterior diameter 

10 
per  cent. 

4 
per  cent. 

13 
per  cent. 

4 
per  cent. 

15 

per  cent. 

5 
per  cent. 

15 
per  cent. 

5 
per  cent. 

13 

Narrow  anteroposterior  and  trans- 
verse diameters 

per  cent. 
6 

per  cent. 

VOL.  II — 16 


482  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

The  average  ratio  of  both  diameters,  based  on  measurements  of  chests 
of  300  children,  was  as  follows:  First  year  of  life,  8  (or  9)  to  10;  first  five 
years,  81  (or  84)  to  100;  five  to  ten  years,  77  to  100;  ten  to  fifteen  years,  72 
(75)  to  100;  fifteen  to  twenty  years,  74  to  100. 

The  state  of  nutrition,  as  shown  by  weight  in  its  proportion  to  height 
(based  on  Quetelet's  figures),  was  normal  or  above  normal  in  64  per  cent,  of 
the  cases. 

2.  Physical  Signs  at  Various  Ages. — One  hundred  and  seventy-one 
of  the  total  number  of  322  examined  children  showed  positive  signs  of  the 
disease.     Total  number  of  families,  146. 


Bom  before  parent  became  tuberculous . 
Born  after  parent  became  tuberculous . . 


Total 
Born. 

Of  These    Liv- 

DlED.            ING. 

Exam- 
ined. 

Tuber- 
culous. 

458 

93         365 

230 

126 

155 

(20  per  cent.) 

41          114 

(26  per  cent.) 

92 

45 

Total 613         134         479         322         171 

An  estimate  of  the  incidence  of  tuberculosis  among  these  children  can 
be  drawn  from  the  consideration  of  77  families  in  which  the  entire  number, 
viz.,  264  children,  were  examined:  in  76  of  them  (29  per  cent,  of  the  total) 
positive  evidence  of  tuberculous  infection  was  found.  An  investigation  of 
the  same  77  famihes  gives  a  total  of  28  per  cent,  of  tuberculosis  for  the  chil- 
dren born  before  the  parent  became  tuberculous,  and  31  per  cent,  for  those 
born  after.  The  higher  percentage  of  tuberculous  cases  among  the  second 
category  of  children  cannot  be  solely  ascribed  to  the  lower  resistance  of 
children  born  of  parents  tuberculous  at  the  time  of  their  conception;  consider- 
ation must  be  given  to  the  closer  contact  between  the  child  and  source  of 
infection  in  the  more  crowded  and  unhygienic  surroundings  into  which  the 
tuberculous  sufferer  gradually  drifts  with  the  progress  of  his  disease. 

The  localization  of  the  disease  in  171  children  pronounced  tuberculous 
was  as  follows: 

Under  1  year  of  age:  Cervical  glands  operated,  1;  meninges,  1;  skin,  1. 

1  to  5  years:  Lungs,  3;  cervical  glands  operated,  2;  joints,  2;  meninges, 
1;  skin,  1;  localization  not  established,  7. 

5  to  10  years:  Lungs,  14;  cervical  glands,  4;  joints,  4;  localization  not 
established,  16. 

10  to  15  years:  Lungs,  22;  cervical  glands,  5;  joint,  1;  spine,  1;  locaUza- 
tion  not  established,  14. 

15  to  20  years:  Lungs,  22;  cervical  glands,  3;  kidney,  1;  localization  not 
established,  4. 

Of  the  99  children  above  20  years  of  age,  examination  included  those 
whose  history  suggested  a  previous  or  existing  tuberculous  infection. 
In  all,  41  showed  positive  signs  of  the  disease:  tuberculosis  of  joint,  1; 
cervical  glands  operated,  5;  pulmonary  incipient,  13;  pulmonary  advanced, 
11;  pulmonaiy  incipient  arrested,  11. 


CHILDREN   OF   THE   TUBERCULOUS. — SACHS.  483 

To  106  cases  diagnosed  as  tuberculous  (chiefly  those  under  fifteen  years 
of  age)  the  cutaneous  tubercuUn  test  was  applied,  with  the  following  results : 
83  positive  reactions,  12  doubtful,  and  11  negative. 

In  31  per  cent,  of  children  under  twenty  years  of  age  pronounced  posi- 
tively tuberculous  the  site  of  the  lesion  could  not  be  established  by  physical 
examination.  The  diagnoses,  made  after  prolonged  observation,  were 
based  on  consideration  of  the  general  condition,  recurring  afternoon  fever, 
other  corroborative  symptoms  and  signs,  differentiation  from  other  diseases, 
and  positive  cutaneous  tuberculin  reaction. 

These  cases,  obscure  as  to  the  location  of  the  tuberculous  focus,  were 
more  numerous  in  the  first  few  years  of  life — amounting  to  44  per  cent,  of 
all  positive  cases  between  one  and  five  years;  42  per  cent,  between  five  and 
ten;  33  per  cent,  between  ten  and  fifteen;  13  per  cent,  between  fifteen  and 
twenty;  none  after  twenty  years  of  age,  where  the  involvement  in  nearly  all 
was  pulmonary. 

With  the  full  knowledge  of  the  fact  that,  in  a  large  proportion  of  obscure 
tuberculous  cases  in  young  children,  the  glands,  particularly  the  bronchial, 
are  the  most  probable  site  of  the  existing  lesion,  still  this  cannot  be  definitely 
estabhshed  in  individual  cases  by  the  present  methods  of  physical  examina- 
tion. The  study  of  the  general  condition,  particularly  the  temperature, 
appeared  to  me  of  the  greatest  importance. 

3.  Range  of  Temperature. — A  study  of  the  temperature  of  children  of 
tuberculous  parentage  frequently  discloses  certain  constant  abnormal  varia- 
tions, which,  considered  in  conjunction  with  other  corroborative  evidence, 
may  point  strongly  to  the  existence  of  tuberculous  infection. 

In  these  children,  in  the  first  decade  of  life,  localization  of  the  process  is 
often  impossible,  and  the  constant  afternoon  fever,  at  times  with  a  wide 
fluctuation' between  morning  and  evening  temperatures,  in  some  cases  the 
periodical  occurrence  of  "waves"  of  high  fever  of  various  duration,  may  be 
the  only  or  the  most  prominent  features.  The  fever  frequently  may  be 
mild,  requiring  systematic  observation  for  its  detection  and  a  knowledge 
of  the  normal  range  of  temperature  for  its  interpretation.  In  order  to 
obtain  a  basis  for  comparison,  diurnal  measurements  of  temperature  were 
taken  in  250  apparently  normal  children  from  the  same  surroundings  as 
the  tuberculous  families  under  discussion  in  this  paper. 

The  result  was  as  follows :  In  the  ages  between  five  and  ten,  the  morning 
temperature  (between  9  and  10),  taken  by  mouth,  varied  between  99.4°  and 
100.4°  F.,  the  average  being  99°  F. ;  the  afternoon  temperature  (4  to  6  p.m.), 
97.4°  to  100.5°  F. ;  average^  99.3°  F.  For  the  ages  between  ten  and  fifteen  the 
morning  temperature  varied  between  98°  and  100.2  °  F. ;  average,  98.2°  F.; 
afternoon,  98°  to  100.2°  F.;  average,  99.2°  F. 

In  the  children  pronounced  tuberculous  in  this  investigation  the  morning 


484  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

temperature  taken  by  mouth,  for  the  ages  between  five  and  ten  years, 
varied  between  97.6°  and  99.6°  F.;  average,  98.3°  F.;  afternoon,  98.2°  to 
101°  F.;  average,  99.7°  F.;  between  the  ages  of  ten  and  fifteen,  morning 
temperature,  97°  to  99.6°  F.;  average,  98.4°  F.;  afternoon,  98.8°  to  100.4°  F.; 
average,  99.5°  F. ;  between  the  ages  of  fifteen  and  twenty,  morning  tempera- 
ture, 97.4°  to  98.6°  F.;  average,  98.2°  F.;  afternoon,  99.2°  to  100.2°  F.;  aver- 
age, 99.6°  F. 

In  a  large  number  of  cases  the  noon  temperature  was  the  highest  of  the 
day. 

4.  Von  Pirquet  Cutaneous  Tuberculin  ^Reaction. — ^The  cutaneous 
tubercuHn  test  of  von  Pirquet  (25  per  cent,  solution)  was  employed  in  217 
children  of  the  322  examined. 

Negative  or 
Positive.  Doubtful. 

8  children  under  1  year 2,  or  25  per  cent.  75  per  cent. 

58        "        from    1  to    6  years 25,  or  43    "       "  57   "       " 

108        "  "       7    "  14      "     53,  or  49    "       "  51    "       " 

28        "  "      15   "  20      "     17,  or  60    "       "  40    " 

15        "  above  20     "     11,  or  73    "       "  27    "       " 

These  figures  agree  to  some  extent  with  the  result  of  the  same  test  em- 
ployed in  460  positive  or  suspicious  cases  of  tuberculosis  by  Dr.  Petruschky, 
whose  article  appears  in  the  May  number  of  "Tuberculosis,"  the  monthly 
pubhcation  of  the  International  Tuberculosis  Association. 

Dr.  Petruschky's  results  were  as  follows : 

Negative  ob 
Positive.  Doubtful. 

12  sucklings  in 0  per  cent.  100  per  cent. 

22  children  from    1  to    6  years  in 50  "        "  50    "      " 

148        "  "       7  to  14       "     " 75  "       "  25    "      " 

69        "  "     15to20       "     "  86  "       "  14    "      " 

The  rare  occurrence  of  positive  cutaneous  tuberculin  reaction  in  the  first 
year  of  life  is  as  significant  as  the  gradual  increase  with  age  in  the  number 
of  positive  reactions. 

Conclusions. 

In  making  this  investigation  cognizance  was  taken  only  of  cases  which 
presented  positive  evidences  of  the  disease. 

In  families  in  which  the  entire  number  of  children  were  examined  (nearly 
all  under  twenty  years  of  age)  the  percentage  of  the  tuberculous  was  29. 

Cases  presenting  large  cervical  glands  or  suspicious  signs  of  possible 
bronchial  adenopathy  (as  shown  by  dullness  and  bronchophony  over  the 
spine  below  the  seventh  cervical  vertebra)  were  not  included  in  this  number 
unless  the  diagnosis  was  made  certain  by  other  positive  findings  and  the 
occurrence  of  tuberculin  reaction. 

The  majority  of  children  under  fifteen  years  of  age  pronounced  tubercu- 
lous did  not  manifest  any  impairment  of  general  condition  sufficient  to  in- 


CHILDREN   OF   THE   TUBERCULOUS. — SACHS.  485 

terfere  with  theii'  school  attendance.  The  constitutional  disturbance  in  a 
large  number  of  cases  was  very  slight. 

With  the  advance  of  age  of  the  children  definite  localization  of  the  tuber- 
culous foci  grows  in  frequency  until,  after  twenty  years  of  age,  pulmonary 
involvement  is  found  in  the  vast  majority  of  positive  cases. 

In  the  crowded  homes  of  the  tuberculous  poor,  at  least  one-third  of  the 
small  children  show  evidences  of  infection,  and  yet,  if  further  development 
of  the  process  takes  place,[and  life  is  not  terminated  by  some  intercurrent 
affection,  it  generally  takes  years  before  the  characteristic  phenomena  of 
adult  phthisis  become  evident. 

While  the  effect  of  infection  in  early  hfe  on  [the  specific  suscepti- 
bility of  the  growing  child  still  remains  to  be  determined  by  laboratoiy  and 
experimental  research,  the  famiUar  type  of  adult  phthisis  is  probably  the 
result  of  successive  infections,  as  suggested  by  the  increasing  number  of 
tuberculous  lesions  and  tuberculin  reactions  with  the  advance  of  life  and  the 
gradual  development  of  the  stigmata  of  the  phthisical  type. 


Los  Nines  de  los  Tuberculoses. — (Sachs.) 

Examen  de  322  ninos  de  padres  tuberculoses:  la'clase  obrera;  Am- 
bient€  favorable  a  la  transmicion  de  la  tuberculosis. 

Veinte  por  ciento  de  los  nines  menores  de  5  anos;  28  per  ciente  entre 
la  edad  de  5  a  10  anos;  25  por  ciento  entre  10  y  15  anes;  14  per  ciente  entre 
le  edad  de  15  a  20  anos. 

Alta  mortalidad  en  los  primeros  aiios  de  vida  de  otras  enfermedades; 
la  mortalidad  de  la  tuberculosis  aumenta  con  la  edad. 

Veinte  y  neuve  por  ciento  de  los  nines  demuestran  [evidencias  posi- 
tivas  de  la  enfermedad;  la  tuberculosis  en  veinte  y  nueve  por  ciento  de  los 
nines  nacidos  antes  que  la  enfermedad  fuese  declarada  en  los  padres;  treinta 
y  uno  por  ciento  en  aquellos  nacidos  despu^s;  La  diferencia  debida  parcial- 
mente  al  contacto  intimo  con  la  infeccion  d  causa  del  aumento  de  la  familia 
y  la  compendiada  capacidad  del  trabaje  de  los  padres. 

El  avance  en  la  edad,  desde  la  infancia  hasta  la  edad  adulta;  desarroUe 
gradual  del  tipe  tisico,  Aumento  frecuente  d,  la  reaccion  de  la  tuberculina. 
Studio  sebre  la  variacion  de  la  temperatura  en  los  nines  aparentemente 
sanes  y  en  los  niiios  de  padres  tuberculoses  baje  las  mismas  cendiciones. 
La  tisis  en  la  edad  adulta  es,  en  muchos  cases,  el  resultado  final  de  la  in- 
feccion durante  la  infancia. 


Les  Enfants  des  Tuberculeux. — (Sachs.) 
Examen  de  322  enfants  de  parents  tuberculeux;  classe  ouvri^re;  mi- 
lieu favorable  k  la  propagation  des  maladies. 


486  SIXTH   INTERNATIONAL  CONGRESS   ON   TUBERCULOSIS. 

20  pour  cent,  des  enfants  au-dessous  de  5  ans;  28  pour  cent,  entre  5  et  10 
ans;  25  pour  cent,  entre  10  et  15;  14  pour  cent,  entre  15  et  20. 

Mortality  elevee,  provenant  de  maladies  autres  que  la  tuberculose, 
pendant  la  premiere  ann^e;  la  mortality  due  a  la  tuberculose  augmente 
avec  I'age. 

29  pour  cent,  de  tons  les  enfants  pr^senterent  des  signes  positifs  de  la 
maladie :  28  pour  cent,  des  cas  de  tuberculose  se  trouv^rent  chez  des  enfants 
n^s  avant  que  le  pere  ou  la  mere  ne  fut  devenu  tuberculeux;  31  pour  cent, 
chez  des  enfants  apr^s  la  tuberculisation  des  parents;  la  difference  est  attri- 
buee  en  partie  au  contact  plus  intime  avec  I'infection  dans  les  habitations 
surpeuplees  ou  la  famille  est  forc^e  de  demenager  quand  le  pere  ne  peut 
plus  travailler. 

Au  fur  et  k  mesure  que  I'enfant  grandit  les  stigmates  du  type  phtisique 
se  developpent  et  les  reactions  h  la  tuberculine  deviennent  plus  frequentes. 
Etude  de  courbes  de  temperatures  chez  les  enfants  apparemment  bien- 
portants  et  les  enfants  de  parents  tuberculeux,  dans  les  memes  conditions. 
La  phtisie  chez  I'adulte  est  souvent  le  resultat  final  d'une  infection  qui 
a  eh  lieu  dans  Tenfance. 


Die  Bander  tuberkuloser  Eltern. — (Sachs.) 

Untersuchung  von  322  Kindern  tuberkuloser  Eltern;  arbeitende  Klasse; 
Umgebung  giinstig  fiir  die  Verbreitung  der  Krankheit. 

Zwanzig  Prozent  der  lender  im  Alter  von  unter  5  Jahren;  28  Prozent 
zwischen  5  und  10  Jahren;  25  Prozent  zwischen  10  und  15;  14  Prozent 
zwischen  15  und  20. 

Hohe  Sterblichkeit  an  nicht-tuberkuloser  Erkrankung  im  ersten  Jahre 
des  Lebens.     Die  Todesrate  von  Tuberkulose  nimmt  mit  dem  Alter  zu. 

Neunundzwanzig  Prozent  aller  Kinder  zeigten  positive  Evidenz  der 
Erkrankung;  28  Prozent  von  Kndern,  die  geboren  wurden  bevor  die 
Eltern  tuberkulos  geworden  waren.  Einunddreissig  Prozent  bei  jenen,  die 
spater  geboren  wurden.  Der  Unterschied  zum  Teile  der  engeren  Beriihrung 
mit  Ansteckung  in  mehr  iiberfiillten  Umgebungen  zugeschrieben,  in  welche 
die  Familie  hineingerat,  mit  einer  Verkiirzung  der  Arbeitsfahigkeit  der 
Eltern. 

Mit  von  der  Kindheit  zum  erwachsenen  Alter  fortschreitender  Entwick- 
lung;  ansteigende  Entwicklung  der  Anzeichen  des  phthisischen  Typus; 
wachsende  Haufigkeit  der  Tuber kulinreaktion;  Studien  iiber  den  Verlauf 
der  Temperatur  bei  anscheinend  gesunden  Kindern  und  den  Kindern  tuber- 
kuloser Eltern  in  derselben  Umgebung.  Phthisis  der  Erwachsenen  in  vielen 
Fallen  das  Endresultat  einer  Infektion  in  der  Kindheit. 


THE  OCCURRENCE  OF  PULMONARY  TUBERCULOSIS 
IN  THE  CHILDREN  OF  TUBERCULOUS  PARENTS. 

By  James  Alexander  Miller,  M.D., 

Director  of  the  Bellevue  Hospital  Tuberculosis  Clinic, 

AND  I.  Ogden  Woodruff,  M.D., 

Assistant  Physician  in  the  Bellevue  Hospital  Tuberculosis  Clinic, New  York. 


This  report  is  based  upon  the  careful  examination  of  150  children  whose 
parents  were  under  treatment  for  tuberculosis  at  the  Bellevue  Hospital 
Tuberculosis  Clinic.  The  examinations  were  made  as  a  part  of  the  routine 
of  the  clinic  in  its  endeavors  to  supervise  the  famihes  and  to  discover 
unsuspected  cases  of  tuberculosis,  and  the  children  observed  lived,  in  most 
instances,  under  unsanitary  conditions  in  tenements,  in  close  association 
with  their  parents,  the  majority  of  whom  had  advanced  tuberculosis. 
With  few  exceptions  these  children  were  not  brought  for  treatment  be- 
cause of  symptoms,  but  were  simply  sent  for  examination  as  a  routine 
procedure  by  the  visiting  nurse.  Their  ages  vary  from  two  to  fifteen  years, 
with  an  average  of  eight  and  one-half  years. 

The  difficulty  of  diagnosing  such  cases  is  easily  appreciated,  but  as  this 
sort  of  preventive  work  marks  the  line  along  which  progress  in  our  knowl- 
edge of  tuberculosis  must  proceed,  our  endeavors  to  establish  a  diagnosis 
in  these  cases  may  be  valuable.  The  most  important  factors  in  diagnosis 
may  be  summarized  as  follows : 

First,  malnutrition. 

Second,  pulmonary  symptoms  and  physical  signs. 

Third,  enlarged  cervical  lymph-nodes. 

Fourth,  hypertrophied  tonsils  and  adenoids. 

Fifth,  the  tuberculin  tests. 

Sixth,  sputum  examinations. 

A  diagnosis  can  be  reached  only  by  a  consideration  of  all  these  factors. 
In  making  a  diagnosis  we  have  considered: 

A.  As  positively  tuberculous:  (1)  All  cases  with  positive  typical  physical 
signs  in  the  lungs.  (2)  All  other  cases  with  constitutional  or  pulmonary 
symptoms,  malnutrition,  or  physical  signs  in  the  lungs  which  reacted  to 
tuberculin. 

487 


488  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

B.  As  douUjul:  (1)  All  children  in  whom  tests  were  not  made  who 
showed  constitutional  or  pulmonary  symptoms  or  atypical  signs  in  the 
lungs,  or  who  showed  malnutrition  alone.  (2)  All  apparently  healthy  chil- 
dren who  reacted  to  tuberculin. 

C.  As  not  tuberculous:  (1)  All  in  whom  tests  were  made  who  did  not 
react.  (2)  All  with  no  symptoms  or  signs  and  of  normal  w^eight  in  which  no 
tests  were  made. 

Of  the  150  cases,  76,  or  51  per  cent.,  were  positively  tuberculous;  43,  or 
29  per  cent.,  were  not  tuberculous;  and  in  31,  or  20  per  cent.,  the  diagnosis 
was  doubtful.  Of  the  tuberculous  cases,  54,  or  71  per  cent.,  presented  defi- 
nite pulmonary  signs.  Of  the  remaining  22,  14  gave  the  history  of  a  cough, 
and  4  others  gave  evidence  of  a  tuberculous  focus  elsewhere  in  the  body. 

Considering  these  diagnostic  factors  we  may  take: 

1.  Malnutrition. — One  hundred  and  seven  children  were  under  the 
standard  weight  for  their  age.  Of  these  a  positive  diagnosis  was  made  in  60, 
or  56  per  cent.;  doubtful  in  20;  and  27,  or  23  per  cent.,  were  considered 
non-tuberculous. 

Out  of  100  cases  in  which  the  height  was  measured,  73  were  under  the 
standard  weight  for  their  height.  Of  these,  31,  or  42  per  cent.,  were  posi- 
tively tuberculous,  19,  or  26  per  cent.,  were  not  tuberculous,  and  23,  or  32 
per  cent.,  were  doubtful. 

2.  Pulmonary  Symptoms  and  Signs. — Eighty-seven  children,  or  58  per 
cent.,  gave  a  history  of  protracted  cough.  Of  these,  a  positive  diagnosis 
was  made  in  65  per  cent.;  73  cases  had  abnormal  physical  signs  in  their 
lungs,  72  per  cent,  of  these  being  positively  tuberculous.  Only  15  children 
had  the  usual  typical  signs  found  in  adults,  and  all  these  children  were  over 
nine  years  of  age.  The  other  58  cases  had  physical  signs  which  have  not 
been  generally  accepted  as  typical  of  tuberculosis.  Thirty-five  had  fine 
localized  subcrepitant  rales  in  some  portion  of  the  chest  other  than  the 
apices  of  the  upper  lobes,  usually  without  any  change  in  percussion-note  or 
breath-sounds.  These  rales,  in  most  instances, — in  28  of  the  35  cases, — were 
found  in  the  region  of  the  nipples,  usually  in  the  fifth  or  sixth  intercostal 
spaces,  just  without  the  midclavicular  line.  In  two-thirds  of  the  cases  they 
were  on  the  left  side;  in  a  few  cases  on  both  sides.  As  a  rule,  these  rales  were 
constant,  but  in  a  few  cases  they  were  inconstant  or  were  developed  during 
a  tuberculin  reaction.  Twenty-three  cases  showed  sibilant  or  sonorous  rales 
over  the  lungs.  These  were  localized  in  various  parts  of  the  chest  in  10 
cases,  in  the  others  more  or  less  generally  distributed.  Of  the  58  cases  with 
atypical  signs,  a  positive  diagnosis  of  pulmonary  tuberculosis  was  made 
in  39,  or  67  per  cent.,  a  doubtful  diagnosis  in  9,  and  a  diagnosis  of  not 
tuberculous  in  10,  or  17  per  cent. 

A  further  analysis  shows :  Of  the  eases  with  fine  rdles,  a  positive  diagnosis 


THE  CHILDREN  OF  TUBERCULOUS  PARENTS. — MILLER  AND  WOODRUFF.      489 

was  made  in  26,  or  74  per  cent. ;  of  those  with  fine  rales  near  the  nipples,  in 
82  per  cent. ;  92  per  cent,  of  those  in  which  tests  were  made  reacted  to  tuber- 
cuhn. 

Of  the  cases  with  signs  of  bronchitis,  13,  or  56  per  cent.,  were  positively- 
tuberculous.  Of  the  10  cases  with  locaUzed  signs,  a  positive  diagnosis  was 
made  in  80  per  cent.,  as  against  5.5  per  cent,  of  those  in  which  the  sibilant 
and  sonorous  rales  were  generally  distributed. 

Considering  the  constitutional  condition  and  pulmonary  signs  together, 
we  found  39  cases  in  which  abnormal  physical  signs  and  malnutrition  were 
associated.  Of  these,  31,  or  79  per  cent.,  were  positively  tuberculous;  6, 
or  15  per  cent.,  were  not  tuberculous,  with  2  doubtful. 

3.  Enlarged  Cervical  Lymph-nodes. — Enlarged  cervical  glands  were 
found  in  79  cases.  Of  these  cases,  47,  or  60  per  cent.,  were  considered  posi- 
tively tuberculous,  10  doubtful,  and  22  not  tuberculous.  They  were  found 
in  three-fifths  of  all  cases  which  reacted  to  tuberculin.  A  slightly  larger 
proportion  of  cases  reacted  in  which  there  was  glandular  enlargement  in 
addition  to  pulmonary  symptoms  and  signs,  than  of  those  cases  in  which 
there  was  no  glandular  enlargement. 

Of  cases  which  had  symptoms  but  no  physical  signs,  those  which  had  also 
enlarged  glands  reacted  in  66  per  cent.,  while  all  such  cases  without  enlarged 
glands  reacted. 

Enlarged  glands  were  present  in  the  same  proportion  in  cases  with 
physical  signs,  as  in  those  without.  Of  the  cases  with  typical  pulmonary 
signs,  enlarged  glands  were  present  in  only  40  per  cent. 

4.  Hypertrophied  Tonsils  and  Adenoids. — ^These  were  present  in 
65  of  our  cases.  Of  this  number,  31,  or  47  per  cent.,  were  considered  tuber- 
culous, 11  doubtful,  and  23  not  tuberculous.  Hypertrophied  tonsils  were 
present  in  only  43  per  cent,  of  those  which  reacted  to  tuberculin.  In  those 
with  pulmonary  signs,  in  only  35  per  cent.  In  cases  which  had  typical 
pulmonary  signs,  in  only  20  per  cent.  Of  cases  with  cough,  7  per  cent, 
more  of  these  without  enlarged  tonsils  reacted  than  of  those  with  them. 

5.  The  Tuberculin  Tests. — One  hundred  and  thirteen  cases  were 
tested  with  ophthalmic  and  cutaneous  tests,  and  of  these,  38  were  also  given 
tuberculin  hypodermatically  as  control.  Seventy-four,  or  65  per  cent.,  of  these 
cases  reacted.  In  95  cases  the  eye  and  skin  tests  were  made  in  the  same  indi- 
vidual. The  results  of  these  local  tests  were  identical  in  all  but  10.  In  9  a 
skin  reaction  occurred  with  no  eye  reaction.  Four  of  these  were  later  in- 
jected with  tuberculin  and  all  reacted.  In  1  case  the  eye  reaction  occurred 
with  no  skin  reaction.  This  took  place  in  an  overgrown  toy  of  fifteen  years, 
and  suggests  a  confirmation  of  the  impression  that  the  skin  test  is  more 
reliable  in  children  than  in  adults. 

We  have  had  no  permanently  injurious  results  from  the  ophthalmic 


490  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

test,  though  some  of  the  reactions  were  very  severe  and  prolonged.  Exacer- 
bation of  the  local  reaction,  both  in  the  eye  and  in  the  skin,  during  a  reaction 
to  the  hypodermic  test  given  from  three  to  five  weeks  later,  was  noted  in 
some  cases,  and  in  the  skin  particularly  presents  a  very  characteristic  picture. 
That  a  positive  skin  reaction  is  presumptive  evidence  of  tuberculosis  is 
supported  by  the  following  facts : 

(1)  Of  9  cases  of  positive  typical  physical  signs  of  tuberculosis  of  the 
lungs,  in  which  the  test  was  made,  all  9  reacted. 

(2)  Of  73  cases  with  suspicious  symptoms,  80  per  cent,  reacted;  of  40 
without  such  symptoms,  only  40  per  cent,  reacted. 

(3)  Of  those  with  physical  signs  in  the  lungs,  both  typical  and  atypical, 
82  per  cent,  reacted;  of  those  with  no  physical  signs,  48  per  cent. 

(4)  Of  those  whose  nutrition  was  below  par  and  with  cough  and  signs  in 
the  chest,  88  per  cent,  reacted;  of  those  without  pulmonary  symptoms  or 
signs,  and  of  normal  weight,  only  25  per  cent,  reacted. 

(5)  Of  the  38  cases  controlled  by  tuberculin  injections  there  was  no  dis- 
crepancy between  the  local  and  hypodermic  test  in  any  case.  Nine  of  these 
were  negative  and  29  positive. 

6.  Sputum  Examinations. — Very  few  of  our  children  expectorated. 
Sputum  examinations  were  made  in  only  16  cases.  In  only  1  case  were 
tubercle  bacilli  found. 

In  a  few  cases  the  method  advocated  of  exciting  a  cough  and  catching 
sputum  on  a  swab  was  tried.     In  no  instances  did  it  give  a  positive  result. 

Conclusions. 
Our  conclusions  are  as  follows: 

1.  The  occurrence  of  pulmonary  tuberculosis  in  children  of  tuberculous 
parents  is  much  more  prevalent  than  is  usually  supposed. 

2.  The  type  of  pulmonary  tuberculosis  generally  seen  in  adults  is  ex- 
tremely rare  in  children  under  ten  years  of  age. 

3.  Given  history  of  infection,  of  the  factors  considered  as  determining  a 
diagnosis,  the  occurrence  of  physical  signs  is  the  most  important,  and  the 
presence  of  fine  rales  in  the  region  of  the  nipple  just  without  the  midclavi- 
cular hne  is  extremely  suggestive  of  a  tuberculous  lesion. 

4.  In  cases  in  which  the  symptoms  are  merely  those  of  bronchitis,  though 
the  localization  is  suggestive,  a  positive  diagnosis  cannot  be  made  from  the 
clinical  picture. 

5.  In  children,  the  cutaneous  tuberculin  reaction  is  more  reliable  than 
the  ophthalmic  reaction,  and  fully  as  much  so  as  the  hypodermic  test.  In 
view  of  the  untoward  effects  which  sometimes  follow  the  instillation  of  tuber- 
culin into  the  eye,  it  is  questionable  whether  this  method  as  a  routine  process 
is  justifiable. 


THE  CHILDREN  OF  TUBERCULOUS  PARENTS. — MH^LER  AND  WOODRUFF.  491 

6.  In  children  between  the  ages  of  two  and  fifteen  years  the  local  cutane- 
ous test  affords  a  reliable  means  of  detecting  a  tuberculous  focus  in  the  body, 
and,  therefore,  in  the  doubtful  cases  is  a  trustworthy  method  of  differentiat- 
ing the  tuberculous  from  the  non-tuberculous. 

7.  Every  case  reacting  to  the  local  tubercuUn  test  does  not  require  the 
sam.e  treatment  as  a  case  of  tuberculosis,  though  it  should  be  kept  under 
careful  observation.  Given  a  tubercuHn  reaction  in  an  apparently  healthy 
child,  the  course  to  be  pursued  should  depend  entirely  on  the  behavior  of 
the  case  under  close  observation. 

8.  Malnutrition  is  sometimes  the  only  appreciable  evidence  of  tubercu- 
losis in  children. 

9.  The  susceptibility  to  infection  of  a  child  seems  to  stand  in  no  relation 
to  the  presence  of  hypertrophied  tonsils  or  adenoid  growths,  nor  does  their 
presence  in  a  suspected  case  appear  in  any  way  to  incline  the  balance  in 
favor  of  tuberculosis. 

10.  The  evidence  that  enlargement  of  the  cervical  lymph-nodes  is  a  de- 
termining factor  in  a  diagnosis  of  tuberculosis  is  not  conclusive.  In  any 
event,  it  does  not  seem  to  have  an  influence  suflSciently  consistent  to  make 
it  of  aid  in  the  diagnosis  of  tuberculosis  in  a  doubtful  case. 

11.  The  examination  of  the  sputum  is  almost  useless  as  an  aid  to  the 
diagnosis  of  early  tuberculosis  in  children. 


Tuberculosis  Pulmonar  en  los  Ninos  de  Padres  Tuberculosos. — (Miller 

Y  Woodruff.) 

Ciento  cincuenta  ninos  de  padres  tuberculosos  fueron  examinados  los 
cuales  forman  la  base  de  este  artfculo. 

De  los  150  casos,  76  6  51  por  cento  se,  encontraron  afectados  de  tuber- 
culosis, 43  6  29  por  cento  se  encontraron  libres  de  tuberculosis  y  en  31  6  20 
por  cento  el  resultado  fue  dudoso.  Los  factores  principales  sobre  los  cuales 
el  diagnostico  fue  hecho  son  los  siguientes:  1.  Mala  nutricion.  2.  Sinto- 
mas  pulmonares  y  sus  correspondiente  signos  fisicos.  3.  Agrandamiento  de 
los  nudos  linfaticos  cervicales.  4.  Hipertrofia  de  las  amigdalas  y  glandulas 
linfaticas.     5.  La  reaccion  de  la  tuberculina.     6.  Examen  del  esputo. 

De  estos  los  sintomas  pulmonares  y  signos  fisfcos  y  la  reaccion  de  la  tuber- 
culina, son  los  mas  valuables  y  consistentes  en  la  diagnostico. 

Los  signos,  fisicos  en  los  ninos,  menores  de  diez  anos,  no  son  aquellos 
signos  tfpicos  que  se  encuentra  en  los  adultos  en  lesiones  tipicas  del  ver- 
tice  del  pulmon,  sino  que  con  mas  frecuencia,  estos  signos  son  los  de  una 
bronquitis  persistente  localizada,  por  lo  general,  en  la  parte  antero-  in- 
ferior del  pecho. 


492  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

La  reaccion  oftalmica,  cutanea  e  hipodermica  de  la  tuberculina  fueron 
mpleados,  y  los  resultados  de  las  reacciones  locales  fueron  corroboradose 
en  todos  los  casos  en  los  cuales  la  reaccion  hipodermica  fue  tambien  hecha. 
La  reaccion  cutanea  fue  mas  constante  que  la  reaccion  oftalmica. 

Agrandamiento  de  los  nudos  linfaticos  cervicales  6  hipertrofia  de  las 
amlgdales  y  otros  tejidos  linfaticos,  no  aparecen  ser  un  factor  determinante 
en  el  diagnostico  de  la  tuberculosis.  Mala  nutricion,  algunas  veces,  es  la 
sola  evidencia  apreciable  de  la  tuberculosis  en  los  ninos.  El  examen  del 
sputo  fue  de  poco  valor. 

-Los  resultados  de  estas  investigaciones  dan  base  al  a  conclucion  que  la 
tuberculosis  pulmonar  en  los  ninos  de  padres  tuberculoses  es  un  hecho. 


Das  Vorkommen  der  Lungen-Tuberkulose  bei  Kindern  tuberkuloser 
Eltern. — (Miller  und  Woodruff.) 

Ein  hundert  und  fiinfzig  Kinder  tuberkuloser  Eltern  waren  als  Grund- 
lage  zu  diesem  Berichte  untersucht  worden. 

Von  den  150  Fallen  waren  76,  oder  51  Prozent,  als  positiv  tuberkulos 
befunden  worden;  43,  oder  29  Prozent,  nicht  tuberkulos;  und  31,  oder  20 
Prozent,  zweifelhaft.  Die  Hauptmomente,  die  bei  der  Diagnose  auftreten, 
sind:  1.  Schlechte  Ernahrung.  2.  Lungen-Symptome  und  physikalische 
Zeichen.  3.  Vergrosserte  cervikale  Lyraphknoten.  4.  Hypertrophierte  Ton- 
sillen  und  Adenoide.     5.  Tuberkulin-Versuche.    6.  Sputum-Untersuchung. 

Von  diesen  scheinen  die  Symptome  und  Zeichen  in  den  Lungen  und  die 
Tuberkulin-Versuche  am  wertvoUsten  und  feststehendsten  zu  sein.  Die 
physikalischen  Zeichen  bei  Kindern  unter  zehn  Jahren  sind  nicht  die  der 
typischen  Spitzen-Verletzung,  wie  sie  fiir  gewohnlich  bei  Erwachsenen 
gefunden  werden,  sind  aber  oft  Anzeichen  einer  bleibenden  lokalisierten 
Bronchitis,  gewohnhch  im  vorderen  unteren  Teile  des  Brustkorbes.  Die 
ophthalmischen,  kutanen  'und  subkutanen  Tuberkulin-Versuche  wurden 
alle  angewendet,  und  die  Resultate  der  lokalen  Versuche  dienten  als  Be- 
starkung  in  alien  Fallen,  in  denen  auch  der  subkutane  Versuch  Beweise 
ergeben  hatte.  Der  kutane  Versuch  war  volhg,  wenn  nicht  mehr  beweis- 
kraftig  als  der  ophthalmische  Versuch. 

Vergrosserte  cervikale  Lymphknoten,  hypertrophierte  Tonsillen,  und 
Adenoide  scheinen  kein  entscheidender  Moment  in  einer  Diagnose  von 
Tuberkulose  zu  sein.  Schlechte  Ernahrung  ist  manchmal  die  einzige 
schatzenswerte  Erklarung  der  Tuberkulose  bei  Kindern.  Die  Untersuch- 
ung  des  Sputums  hatte  wenig  Wert. 

Die  Resultate  dieser  Forschung  fuhren  zu  der  Schlussfolgerung,  dass 
Lungentuberkulose  bei  Kindern  tuberkuloser  Eltern  sehr  haufig  ist. 


A  CLINICAL  STUDY  OF  THE  TRANSMISSION  AND 

PROGRESS  OF  TUBERCULOSIS  IN  CHILDREN 

THROUGH  FAMILY  ASSOCIATION. 

By  Cleaveland  Floyd,  M.D.,'and  Henry  I.  Bowditch,  M.D., 

Boston,  Mass, 


The  solution  of  any  great  problem,  vitally  affecting  the  welfare  of  the 
State  and  nation,  should  be  appUcable,  first,  to  the  home,  that  unit  of  national 
foundation.  Where  the  home  is  menaced,  the  State  is  always  endangered. 
Tuberculosis  invariably  has  been  a  disease  of  the  household,  a  fact  the  more 
important  when  considered  together  with  the  rapid  growth  of  municipal 
communities.  Not  only  is  it  a  distinct  danger  to  the  family,  but,  from  the 
very  nature  of  its  chronicity  it  is  an  enormous  economic  loss  to  the  community. 

In  endeavoring  to  control  tuberculosis,  proper  consideration  should  be 
given  to  the  child.  Too  frequently  the  children  of  to-day  are  the  consump- 
tives of  to-morrow,  being  handicapped  by  heredity  and  exposed  through 
family  associations.  The  solution  of  the  problem,  therefore,  must  embrace 
the  sick,  and  the  endangered  as  well.  The  work  in  Boston  has  included  not 
only  the  phthisical  patient,  but  also  his  family.  Records  of  the  public 
charities  and  hospitals  have  been  searched  in  quest  of  cases  of  tuberculosis. 
Where  disease  has  appeared  within  the  past  four  years,  the  household  has 
been  visited  and  investigated,  and  again  and  again  the  need  of  medical  super- 
vision has  been  most  apparent.  In  this  way  the  incipient  case  has  been 
discovered,  predisposition  controlled,  and  the  well  maintained  in  health. 

Infltiences  Favoring  Injection  in  the  Child. — ^The  effect  of  tuberculosis  on 
the  mortality  of  early  years  shows  its  influence  to  be  greatest  during  infancy. 
This  death-rate,  as  repeated  observations  show,  appears  to  decrease  slowly 
as  the  child  grows  older.  Susceptibility  is  at  its  height  in  this  early  period, 
and  where  a  predisposition  through  heredity  is  added  to  a  soil  not  unfavor- 
able for  the  growth  of  the  disease,  the  likelihood  of  infection  is  vastly  in- 
creased. Children  are  peculiarly  susceptible  to  unhygienic  surroundings. 
Overcrowding,  lack  of  fresh  air  and  sunlight,  dirt,  neglect,  and  improper 
food,  the  natural  environment  of  the  majority,  all  tend  to  increase  the 
normal  low  resistance  of  the  child  at  this  period.  The  influence  of  measles, 
whooping-cough,  and  influenza  is  known  to  exert  a  powerful  predisposing 
effect  toward  tuberculosis.     The  activity  of  the  lymphoid  tissues  of  the  body 

493 


494  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

in  early  life  and  the  onset  of  puberty  are  physiological  phenomena  of  con- 
siderable importance. 

It  must  not  be  forgotten,  however,  that  the  habits  and  characteristics 
of  the  child  in  daily  life  have  an  important  part  to  play.  The  close  intimacy 
of  cliild  with  child,  its  parents  and  neighbors,  in  school  and  at  home,  mate- 
rially aids  in  spreading  the  disease. 

The  presence  of  tuberculosis  in  the  household  plays  a  very  important 
part  in  the  life  of  the  child.  Even  when  cleanliness  of  person  and  the  habits 
of  the  consumptive  are  ideal,  there  is  still  a  minimum  amount  of  danger  of 
infection.  When  carelessness  and  ignorance  abound,  contagion  is  not  only 
probable,  but  very  frequent. 

Modes  of  Infection. — Where  we  deal  with  a  constant  exposure  to  disease, 
the  modes  of  infection  must  necessarily  be  various  and  frequently  multiple. 
The  two  prominent  paths  of  infection,  ingestion  and  inhalation,  have 
contributed  greatly  without  doubt,  but  in  any  individual  case  it  was 
impossible  to  determine  which  manner  of  infection  occurred. 

In  our  study  of  1000  children  it  appears  that  whatever  the  mode  of  en- 
trance might  have  been,  probably  direct  transmission  of  the  disease  from 
parent  to  child  was  the  most  important  factor.  Of  these  cases,  679  have 
been  in  immediate  contact  with  tuberculosis  in  the  home,  and  of  this  number 
36  per  cent,  showed  definite  signs  of  pulmonary  consolidation.  This  type 
of  infection  has  been  strikingly  demonstrated  in  a  large  number  of  instances. 
Following  one  open  case  of  tuberculosis  in  a  parent,  evidence  of  the  disease 
was  found  in  all  but  one  of  five  children.  This  has  been  true  not  only  of 
one  but  of  many  families. 

The  respiratory  tract  is  not  the  only  vulnerable  point  in  the  youthful 
organism.  The  lymphoid  tissues  of  the  throat,  by  means  of  adenoids  and 
tonsils,  present  a  very  favorable  point  of  entrance  for  the  tubercle  bacillus. 
They  aid  directly  in  the  transmission  of  the  disease,  and,  by  obstructing  the 
upper  air-passages  and  producing  improper  breathing,  favor  the  production 
of  pulmonary  tuberculosis 

The  systematic  laryngoscopical  examination  of  our  cases  shows  about 
50  per  cent.  (493  children)  to  have  hypertrophied  tonsils,  whereas  operable 
adenoid  growths  appeared  in  only  about  145.  Tonsillotomy  and  adneoid- 
ectomy,  even  when  imperative,  were  necessarily  rarely  performed,  on  ac- 
count of  popular  prejudice.  Of  the  few  operated  on,  no  tubercles  were 
demonstrable  pathologically  in  the  tissues  removed. 

In  only  11  instances  did  infection  point  to  the  glands  of  the  neck,  and 
of  this  number  only  5  showed  pulmonary  involvement.  In  regard  to  the 
localization  of  infection  in  bone  or  joint,  except  for  4  cases  of  tuberculosis 
of  the  hip  and  1  of  the  finger,  this  type  of  infection  has  not  been  encountered. 

Invasion  of  the  serous  cavities,  the  peritoneum,  and  the  meninges  was 


TRANSMISSION  THROUGH  FAMILY  ASSOCIATION. — FLOYD  AND  BOWDITCH.      495 

discovered  in  only  two  or  three  instances.  This  is  of  interest  when  we  note, 
from  the  report  of  a  small  phthisis  hospital,  that  11  children  out  of  24 
born  of  tuberculous  mothers  died  of  tuberculous  meningitis. 

Incidence. — ^The  early  detection  of  intrathoracic  tuberculosis  in  the  in- 
fant or  child  is  frequently  accomplished  only  with  extreme  difficulty.  Very 
often  the  actual  condition  in  the  lungs  is  only  suspected,  and  a  positive 
diagnosis  is  not  made  until  lesions  are  extensive  or  general  miliary  disease 
supervenes.  The  explanation  of  this  state  of  affairs  Ues  in  the  peculiar 
anatomical  condition  in  the  chest  of  the  child,  where  the  pathological  pro- 
cess must  be  of  relatively  large  extent  to  be  evident.  The  chronic  sore 
throat  and  persistent  laryngitis,  with  its  cough,  so  frequently  occurring  in 
the  children  of  the  poor,  distract  attention  from  the  lungs.  The  existence 
of  pulmonary  disease  is  frequently  overlooked  because  of  the  presence  of 
measles  or  pertussis.  The  non-appearance  of  sputum  is  a  serious  handi- 
cap. With  cliildren  under  constant  supervision,  this  difficulty  may  be 
obviated,  as  shown  by  Holt,  but  the  dispensary  clinic  cannot  so  readily 
profit  by  the  swab  method.  We  have  been  able  to  collect  sputum  in  only 
62  of  these  cases,  and  in  only  3  of  these  were  bacilli  present. 

It  is  difficult  to  obtain  an  accurate  estimate  of  the  extent  of  pulmonary 
tuberculosis  in  early  life,  and  wide  diversity  of  opinion  exists  in  regard  to  it. 
Morse  states  that  pulmonary  lesions  are  comparatively  rare  before  puberty, 
but  are  of  more  common  occurrence  in  childhood  than  in  infancy.  Squire 
says  of  phthisis  in  the  United  Kingdom  that  it  is  the  most  common  and 
fatal  of  all  diseases  of  infancy  and  childhood.  The  Registrar-General's 
report  for  1905  for  England  and  Wales  showed  a  total  of  16,650  cases.  On 
the  other  hand,  systemic  examination  of  school-children  in  London  has 
shown  that  among  1670,  only  8,  or  0.47  per  cent.,  showed  signs  of  phthisis, 
and  when  those  with  doubtful  signs  were  taken  into  account,  it  made  a 
total  of  1.3  per  cent.  Mackensie  found  18  cases  in  600  school-children  in 
Edinburgh,  and  Robertson,  6  cases  among  806  in  Leith.  Leubuscher  found 
2  cases  in  1400  school-children  in  Germany,  whereas  Grancher,  in  Paris, 
found  that  about  15  per  cent,  of  14,226  children  gave  evidence  of  glandular 
or  pulmonary  tuberculosis.  This  author  also  finds  that  about  25  per  cent, 
of  children  of  tuberculous  parents  are  similarly  affected  or  predisposed  to 
the  disease.  These  results  were  obtained  in  an  examination  of  the  average 
school-child,  the  majority  being  apparently  well  and  not  exposed  to  the 
disease. 

Among  679  children  taken  from  the  poorest  homes  of  Boston,  in  which  470 
contained  living  consumptives,  and  in  179  more  of  which  there  had  been  re- 
cent deaths  from  the  disease,  there  were  definite  signs  of  pulmonary  in- 
volvement in  36  per  cent.  More  than  66  per  cent,  of  the  entire  number 
showed  symptoms  of  the  disease.    Of  321  children,  living  amid  poverty  and 


496  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

neglect,  who  were  brought  for  examination  on  account  of  suspicious  symp- 
toms, about  30  per  cent,  were  looked  upon  as  tuberculous,  although  not 
directly  exposed  in  the  home. 

In  regard  to  post-mortem  statistics,  J.  Comby  has  published  reports 
from  the  hospitals  of  Paris,  showing  that  38.5  per  cent,  of  children  examined 
showed  tuberculous  lesions.  Miiller,  in  Munich,  found  43  per  cent,  out  of 
500  examinations.  Hamburger  and  Sluka  discovered  41  per  cent,  in  401 
post-mortems  in  children  under  fifteen  years  of  age.  These  figures  apply  to 
tuberculosis  occurring  in  any  portion  of  the  body  in  children  dying  from 
various  causes.  Hamburger's  tables  showed  that  pulmonary  infection  was 
present  in  50  per  cent,  of  the  cases,  and  that  the  bronchial  glands  were  in- 
volved in  98  per  cent.  In  examining  all  necropsy  reports,  however,  it 
should  be  remembered  that  many  tuberculous  foci  may  have  occurred  secon- 
dary to  the  terminal  disease,  and  that  many  more  are  never  discovered  during 
life.  These  reports  are  taken  from  general  hospitals.  If  autopsies  could  be 
obtained  on  a  series  of  children  such  as  we  have  had  under  olDservation,  very 
few  would  probably  be  found  free  from  tuberculosis.  It  is  interesting  to 
note  that  the  percentage  of  cases  showing  tuberculosis  at  necropsy  tallies 
closely  with  our  records  of  cases  with  pulmonary  tuberculosis. 

Other  Factors  Influencing  Infection. — As  to  the  part  played  by  milk  in 
the  production  of  tuberculosis,  in  children  especially,  McCaw  calls  attention 
to  the  fact  that  of  26,193  cases  under  treatment  for  various  disorders  in 
Belfast,  20  per  cent,  under  five  years  showed  tuberculosis,  and  of  these, 
40  per  cent,  were  of  the  surgical  type  (bone  and  glandular).  In  other 
English  cities,  as  London  and  Manchester,  also  in  Glasgow  and  Edinburgh, 
the  predominance  of  surgical  tuberculosis  treated  in  hospital  clinics  has 
been  marked.  McCaw  further  states  that  the  general  consensus  of  opinion 
is  that  surgical  tuberculosis  is  generally  of  the  bovine  type,  and  that  bovine 
and  human  infection  do  not  commonly  occur  in  the  same  case.  With  us, 
where  infection  was  probably  due  to  the  human  type  in  the  great  majority 
of  instances,  every  opportunity  of  infection  being  at  hand,  only  11  cases  of 
glandular  tuberculosis  and  5  of  bone  infection  occurred.  It  must  be  re- 
membered that  these  were  not  selected  cases,  only  in  so  far  as  every  exposed 
child  possible  was  examined.  Why,  then,  has  it  happened  that  the  surgical 
types  have  been  so  infrequent?  This  question  cannot  be  answered  unless 
we  take  the  position  that  surgical  tuberculosis  is  produced  by  the  bovine 
bacillus,  and  in  our  cases  the  human  type  of  infection  has  been  reproduced 
by  direct  transmission. 

Concerning  the  period  of  latency  of  phthisis  in  children,  it  would  seem, 
from  a  number  of  observations,  that,  following  direct  exposure,  only  a  few 
months  intervened  before  active  symptoms  appeared.  In  others,  however, 
the  intervals  have  been  considerably  longer.    The  great  difference  of  sus- 


TRANSMISSION  THROUGH  FAMILY  ASSOCIATION. — FLOYD  AND  BOWDITCH.      497 

ceptibility  to  tuberculosis  in  different  children  has  been  very  noticeable. 
Even  when  placed  amid  similar  surroundings  and  exposed  for  the  same  period 
of  time  they  vary  much  in  this  respect. 

The  size  of  the  cardiac  area,  in  its  relation  to  the  development  of  phthisis, 
is  often  important.  In  the  measurement  of  800  hearts  in  children,  our  re- 
sults were  remarkably  uniform  both  as  to  age  and  development.  In  a  very 
few  the  carcUac  area  v/as  distinctly  undersized.  Even  in  the  poorly  de- 
veloped and  nourished  the  heart  did  not  seem  to  have  suffered  in  develop- 
ment. VaKoilar  lesions  were  infrequent,  only  10  cases  of  mitral  regurgita- 
tion and  2  of  mitral  stenosis  being  present. 

Type  of  Disease — Infant  or  Adult. — In  any  large  children's  hospital  two 
types  of  tuberculosis  are  common — the  general  disseminated  and  the  chronic 
phthisis  of  the  adult.  The  latter  group,  chronic  phthisis,  includes  prac- 
tically all  our  cases,  only  two  cases  of  general  miliary  tuberculosis  having 
been  detected  and  one  proved  at  autopsy.  What  bearing  this  has  on  in- 
di\ddual  susceptibility  we  do  not  know.  In  these  cases  infection  has,  per- 
haps, been  conveyed  in  small  repeated  doses,  and  the  stimulation  of  the 
body  resistance  thereby  has  prevented  diffuse  lesions.  Be  this  as  it  may,  the 
great  preponderance  of  the  adult  type  of  lesion  is  certainly  noteworthy. 

Sijni'ptoms  and  Signs. — ^Many  a  child  with  few  or  no  symptoms  will,  in 
the  study  of  a  phtliisical  family,  show,  on  examination,  genuine  evidence  of 
tuberculosis  in  some  portion  of  the  body.  The  acute  respiratory  symptoms 
that  often  follow  measles,  or  are  associated  with  the  common  cold,  will  fre- 
quently be  overlooked,  and  later  a  semiquiescent  pulmonary  lesion  be  dis- 
covered. With  the  repetition  of  colds  and  sore  throat,  from  neglect  or 
diseased  nasopharyngeal  conditions,  the  pulmonary  process  may  be  lighted 
up  or  increase  in  extent  and  make  itself  apparent.  Languor,  pallor,  and  loss 
of  strength  and  appetite  are  the  first  symptoms  noted.  Night-sweats  are 
frequent,  and  loss  of  weight  is  rapid.  Cough  is  generally  constant  and  dis- 
tressing. Hemoptysis  is  uncommon.  SUght  evening  pyrexia  is  most 
significant.  Cough,  however,-  is  so  common  in  the  child  that  too  much 
dependence  must  not  be  placed  upon  this  symptom.  Young  examined 
337  children  under  fifteen  years  of  age  in  trying  to  estimate  other  etiological 
factors  for  cough  besides  pulmonary  tuberculosis.  Of  this  number,  only 
45  showed  pulmonary  lesions.  In  our  cases  262  showed  involvement  of 
one  or  both  apices  of  the  lungs.  In  about  100  the  lesions  were  equally 
divided  between  the  middle  and  lower  lobes.  The  extent  of  the  lesion  varied 
greatly,  and  apparently  had  little  connection  with  the  length  of  exposure  to 
infection.  Very  few  lesions  had  advanced  to  cavity  formation,  and  where 
the  disease  was  extensive,  the  process  generally  took  the  type  of  acute  bron- 
chopneumonia with  septic  manifestations. 

Diagnosis  by  Various  Means  and  their  Value. — ^The  younger  the  child, 


498  SIXTH   INTERNATIONAL  CONGRESS   ON   TUBERCULOSIS. 

the  more  difficult  it  is  to  diagnose  the  lesion,  especially  in  its  incipient  stage. 
A  careful  consideration  of  the  family  history  and  the  clinical  symptoms  is 
imperative,  in  order  to  arrive  at  a  correct  conclusion.  In  the  differential 
diagnosis  of  chronic  pulmonary  phthisis  the  group  of  symptoms  in  cliildren 
may  be  closely  simulated  by  a  numl^er  of  conditions.  Phthisis  and  asthma 
may  frequently  be  associated,  and  we  should  not  be  misled  by  the  more 
evident  process.  The  diffuse  catarrhal  lesions  in  the  lungs,  the  expiratory 
distress,  and  the  characteristic  sputum,  if  it  can  be  obtained,  may  aid  us 
in  the  detection  of  the  asthma.  The  symptoms  following  acute  nasal  and 
throat  infections  are  often  confusing,  and  unless  the  upper  air-passages  are 
studied,  the  diagnosis  may  long  remain  uncertain.  The  cough  in  tonsillar 
hypertrophy  with  nasopharyngitis  and  the  expectoration  of  mucus,  general 
debility,  and  loss  of  strength  often  make  it  impossible  to  exclude  a  begin- 
ning pulmonary  lesion.  When  tuberculosis  of  the  bronchial  glands  is  pres- 
ent, with  night-sweats,  cough,  and  dyspnea,  in  addition,  perhaps,  to  local 
signs  at  the  upper  portion  of  one  of  the  lungs,  time  is  required  to  settle  the 
question  as  to  whether  or  not  the  lesion  is  pulmonary.  The  recurrent 
attacks  of  bronchitis  are  often  followed  by  phthisis,  and  may  later  conceal  it. 
Even  after  we  have  learned  all  that  clinical  methods  can  tell  us,  many  con- 
ditions will  be  obscure,  and  laboratory  methods  will  be  demanded. 

Repeated  examination  of  the  sputum,  when  it  can  be  obtained,  will 
often  aid  the  diagnosis,  and  occasionally  tubercle  bacilli  will  be  found  when 
the  pulmonary  examination  is  negative.  Where  the  laryngologist  is  at  hand, 
this  may  be  collected  from  the  larynx  on  a  swab.  In  older  children,  with 
training  and  the  aid  of  an  expectorant  sputum  can  be  obtained  in  a  consider- 
able number  of  cases.  The  use  of  the  stomach-tube  for  the  purpose  of  ob- 
taining specimens  of  swallowed  mucus  will  probably  be  a  method  mostly 
confined  to  hospital  practice.  The  employment  of"  tuberculin  is  of  real 
value  and  may  stamp  many  a  doubtful  case  as  tuberculosis.  The  injection 
of  tuberculin  subcutaneously  is  the  most  accurate  diagnostic  means  we  have, 
and  its  prompt  and  definite  reaction,  general  and  local,  will  not  only  decide 
whether  or  not  the  case  is  tuberculosis,  but  will  often  indicate  whei*e  the 
process  is  located.  The  cutaneous  and  ophthalmic  reactions  have  been  found 
of  great  value,  especially  because  of  their  simplicity.  With  the  cutaneous 
reaction  there  are  rarely  any  constitutional  symptoms  and  no  dangers  are 
connected  with  its  use.  It  is  generally  reliable  in  its  results,  but  in  how  large 
a  percentage  of  cases  of  tuberculosis  a  positive  reaction  occurs  is  still  unde- 
termined. Engel  and  Bauer,  having  used  the  cutaneous  reaction  on  about 
300  cases,  conclude  that  it  is  of  great  diagnostic  value.  We  have  found  the 
ophthalmic  reaction  of  value  in  a  number  of  cases  in  confirming  our  suspic- 
ions as  to  the  presence  of  tuberculosis.  Because  of  the  increasing  number 
of  reports  of  injury  done  to  the  tested  eye,  and  since,  in  our  Q^vn  experience. 


TRANSMISSION  THROUGH  FAMILY  ASSOCIATION. — FLOYD  AND  BOWDITCH.      499 

we  have  had  three  cases  of  phlyctenular  conjunctivitis,  we  have  relied  on  the 
other  methods  of  administration.  In  a  number  of  cases  we  used  both  meth- 
ods, and  found  that  they  frequently  gave  identical  results,  and  then,  again, 
one  was  positive  and  the  other  negative.  In  fourteen  instances  in  which  the 
cutaneous  reaction  was  negative  the  ophthalmic  reaction  was  positive.  Of 
73  children  giving  a  negative  examination,  30  gave  a  positive  tuberculin 
reaction.  Of  174  children  suspected  of  tuberculosis,  112  gave  a  positive 
reaction.  These  newer  methods  of  giving  tuberculin  as  an  aid  to  diagnosis 
have  been  found  of  value  in  confirming  our  suspicions  in  doubtful  cases  and 
in  leading  us  to  consider  slight  signs  and  symptoms  of  more  importance. 

The  use  of  the  x-ray  in  conjunction  with  these  other  measures  has  been 
found  of  great  value,  an  expert  having  been  employed  to  interpret  our 
radiographs.  It  has  been  learned  that  the  most  careful  examination  will 
fail  to  detect  the  true  extent  of  a  tuberculous  process,  and  that  one  that  ap- 
pears well  localized  may  be  very  diffuse.  All  means  and  agencies  at  our 
disposal  have  been  used  in  attempts  to  reach  a  decision.  Even  then  time 
and  repeated  observations  have  been  necessary. 

Treatment. 
In  our  community,  while  the  educational  movement  is  rapidly  making 
progress  in  regard  to  tuberculosis  among  all  classes  of  people,  our  duty  to 
children  has  not  been  fully  realized.  No  adequate  provision  has  yet  been 
made  to  place  these  children  in  suitable  environment,  so  that  they  may  re- 
gain their  health.  The  problem  of  removing  the  infected  member  of  the 
family  is  being  well  worked  out,  but  until  we  can  care  for  all  the  ignorant 
and  careless  consumptives,  our  problem  in  regard  to  children  will  still  remain 
unsolved.  Much,  however,  can  be  done  through  isolation,  education,  and 
cleanhness.  We  have  had  a  considerable  number  of  children  under  observa- 
tion in  day  camps  and  in  the  countiy,  and  the  results  have  exceeded  our  ex- 
pectations. Not  only  has  tlie  general  improvement  been  rapid,  but  a  number 
of  active  lesions  have  become  quiescent  after  a  few  weeks'  treatment.  It 
would  seem  that  the  child,  at  its  receptive  age,  can  be  easily  taught  the  meth- 
ods of  hygienic  living,  and  the  recuperative  powers  of  the  body  at  this  stage 
make  the  opportunity  and  the  results  of  treatment  very  promising. 

Prophylaxis. 
In  order  better  to  protect  our  children  the  following  measures  are  im- 
portant: (1)  Early  notification  of  all  births.  (2)  Better  inspection  and 
control  of  the  cities'  milk-supply.  (3)  Systematic  school  inspection.  (4) 
Housing  reform.  (5)  Segregation  of  advanced  cases.  (6)  Compulsory 
notification  of  the  disease.  (7)  Provision  for  the  care  of  pulmonary  tubercu- 
losis in  children.     (8)  Education  of  all  school-children  on  matters  of  general 


500  SIXTH  INTERNATIONAL  CONGRESS   ON   TUBERCULOSIS. 

hygiene.  Nearly  all  these  measures  are  being  enforced  in  Massachusetts, 
and  as  the  forces  of  sanitation  and  education  advance,  the  problem  of  pre- 
venting tuberculosis  is  nearer  solution. 

STATISTICS. 

Number  of  children,  1000.     Boys,  475;  girls,  525. 

Under  one  year,  35.     Between  one  and  five  years,  249.     Between  five  and  fifteen 

years,  716. 
Total  number  exposed  to  tuberculosis  in  the  home,  679. 
Total  not  exposed  to  tuberculosis  in  the  home,  321. 
Total  exposed  in  the  home  showing  pulmonary  lesions,  254. 
Family  History:     Living  phthisical  patients  in  family,  500.     Died  of  phthisis  (within 

four  years),  179.     Negative  history  of  phthisis,  320. 

Group  A  (Children  under  One  Year). 

Diagnosis.  Physical  Examination. 

Negative 27  Negative 28 

Pretuberculous 1  Catarrhal 7 

Bronchitis 5  Consolidation 0 

Miliary  tuberculosis 2 

Exposed,  25.  Total,  35. 

Group  B  (Children  from  One  to  Five  Years  of  Age). 

Children  fkom  One  to  Five  Years  of 
Diagnosis.  Age.  Examination. 

Negative 152  Negative 174 

Pretubercular 12  Signs  of  consolidation 39 

Tubercular 10  Catarrhal  signs 36 

Bronchitis 27 

Phthisis  (?) 39 

Phthisis 9 

Exposed,  171.     Total,  249. 

Group  C  (Children  from  Five  to  Fifteen  Years  op  Age). 

Children  from  Five  to  Fifteen  Years 
Diagnosis.  of  Age.  Examination. 

Negative 526  Negative 424 

Pretubercular 50  Signs  of  consolidation 222 

Tubercular 49  Catarrhal 70 

Bronchitis 43 

Phthisis  (?) 210 

Phthisis 38 

Exposed,  481.     Total,  716. 


Throat  examinations:   Tonsils  hypertrophied,  493;    adenoids,  145. 

Heart  lesions:   Mitral  stenosis,  2;    mitral  regurgitation,  10. 

Lung:   Apical  lesion,  262;   middle  and  lower  lobe  involvement,  100. 

Tuberculin. 
Children  negative  on  examination,  73;  positive  to  tuberculin,  30. 
Children  suspected  of  tuberculosis,  178;  positive  to  tuberculin,  112. 
Positive  reactions,  142;  negative,  97.     Total,  239. 

Explanation  of  Nomenclature. 

Pretubercular,  patients  having  tubercular  symptoms  with  negative  reaction  examination. 

Tubercular,  patients  having  tubercular  symptoms  with  tubercuhn  reaction. 

Phthisis  (?)  patients  having  tubercular  symptoms  and  signs  of  pulmonary  consolida- 
tion. 

Phthisis  patients  having  signs  and  symptoms  of  phthisis  with  positive  sputum  or 
tuberculin  reaction. 


TRANSMISSION  THROUGH  FAMILY  ASSOCIATION. — FLOYD  AND  BOWDITCH.  501 

BIBLIOGRAPHY. 

M.  Adolphe  D'Espine:     "Early  Diagnosis  of  Incipient  Thoracic  Tuberculosis,"  Bull. 

de  I'Academie  de  Med.,  Jan.  29,  1907,  vols.  Ivii,  Iviii,  p.  167. 
M.  J.  Comby:     "Etiologie  de  la  Tuberculose  Infantile,"  La  Presse  Med.,  December 

22,  1906,  vol.  xiv,  p.  833. 
A.  Calmette:     "Etiologie  de  la  Tuberculose  Infantile,"  La  Presse  Med.,  1906,  p.  765. 
C.  W.  Bridge:     "Tuberculosis  in  Children,"  Chicago  Med.  Recorder,  vol.  xxiii,  p.  436. 
C.  R.  Kerser:     "Treatment  of  the  Common  Tubercular  Affections  in  Children,"  Brit. 

Jour.  Children's  Dis.,  July,  1907,  vol.  iv,  p.  278. 
L.  E.  LaFetra:     "Tubercular  Cervical  Lymph-Nodes  in  Infants,"  Arch.  Pediat.,  vol. 

xxiv,  p.  418. 
Jos.  Stark:     "Surgical  Tuberculosis  and  the  Opsonic  Index,"  Brit.  Med.  Jour.,  1907, 

vol.  i,  p.  1336. 
Wallace:     "Etiological  Factors  in  Bone  Tuberculosis  in  Children,"  Med.  Rec,  New 

York,  vol.  Ixx,  p.  908. 
John  Lovett  Morse:     "Tuberculosis  of  the  Kidney  in  the  Infant,"  Med.  Jour.,  vol. 

Lxxiv,  p.  1081. 
H.  H.  Felton:     "A  Case  of  Intestinal  Obstruction  in  a  Child  due  to  Tubercular  Perito- 
nitis following  Bronchopneumonia,"  Med.  Rec,  October,  vol.  Ixx,  p.  614. 
Johnson:     "Forms   of   Surgical   Tuberculosis   in   Children,"   Clinical   Jour.,   London, 

vol.  xxviii,  p.  385. 
Squire:     "Pulmonary  Tuberculosis  in  Children,"  Brit.  Med.  Jour.,  1906,  vol.  ii,  p.  133. 
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Jour.,  1908,  vol.  i. 
M.  Grancher:     "La  tuberculose  ganglio-pulmonaire  dans  I'^cole  parisienne,"  Le  Bulle- 
tin Med.,  November,  1906,  vol.  Ixxxvii. 
McCaw:     "Tuberculosis  in  Childhood  and  MiUc,"  Brit.  Med.  Jour.,  December  21,  1907. 
Kelynack:     "Care  of  Tubercular  Children,"  Brit.  Med.  Jour.,  September  21,  1907. 
Lancet:     "Revealed  Tuberculosis  in  Children  from  Four  to  Fifteen  Years,"  London, 

December,  28,  1907. 
"Three  Years'  Work  at  Sea  Breeze  Hospital,"  Med.  Rec,  New  York,  March  7,  1908. 
Reviere:     "Tuberculin  Treatment   of  Tuberculosis  in  Children,"   Brit.   Med.    Jour., 

October  26,  1907. 
Morse:     "Treatment  of  Tuberculosis  in  Infants  and  Children,"  New  York  Med.  Jour., 

February  28,  1908. 
Scott:     "Reliability  of  Calmette's  Ophthalmo-tuberculin  Reaction,"  Med.  and  Surg. 

Jour.,  April,  1908. 
Butler:     "Calmette's  Ocular  Reaction,"  Brit.  Med.  Jour.,  April  18,  1908. 
"Ocular  Reaction  to  Tuberculin,"  Berl.  klin.  Woch.,  xlv,  No.  4,  Januarj^  27,  1908. 
"Ocular  and  Cutaneous  Reaction  to  Tuberculin,"  Berl.  klin.  Woch.,  No.   5,   February 

3,  1908. 
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xxxiv.  No.  7,  February  13,  1908. 
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Children,"  Presse  M^d.,  September  26,  1907,  No.  78. 
"Cutaneous  and  Ocular  Reaction  to  TubercuUn,"  Jour.  Am.  Med.    Assoc,    October 

26,  1907. 
"Experiments  with  von   Pirquet's  Cutaneous  Reaction  to  Tuberculin,"   Berl.   klin. 

Woch.,  xliv.  No.  37,  September  16,  1907. 
Satterlee:     "Serious   Results  of  Ocular  Tuberculin  Test,"  Jour.   Am.   Med.   Assoc, 

June  27,  1908. 


Transmici6n  y  el   Progreso  de  la  Tuberculosis  en  los  Nifios  por  Medio 
de  la  Associati6n  con  la  Familia. — (Floyd  y  Bowditch.) 

El  articulo  consiste  del  estudio  dc  unos  novecientos  cases  de  tuberculo- 
sis en  los  ninos  observados  por  algunos  meses  en  el  Hospital  de  Tfsicos  de 
Boston.    La  edad  de  los  pacientes  fluctua  entre  pocos  meses  y  quince  anos. 


502  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

La  mayor  parte  de  ellos  han  estado  expuestos  a  la  infeccion,  por  un  tiempo 
variable,  debido  a  la  presencia  de  tuberculosis  en  el  seno  de  la  familia.  Por 
medio  de  repetidos  examenes  fisicas,  del  esputo,  la  aplicacion  de  los  rayos 
X  y  la  reaccion  de  la  tuberculina,  los  resultados  demuestran  que  cerca  de 
40  por  ciento  presentan  lesiones  definitivas  de  tuberculosis  pulmonar,  26 
por  cient.  presentan  signos  y  sintomas  de  tuberculosis.  Examen  de  la 
garganta  se  hizo  en  casi  todos  los  casos  y  en  cerca  de  50  por  ceinto  se  en- 
contraron  condiciones  prejudiciales  a  la  respiracion  normal.  En  un  gran 
numero  de  los  casos  se  encuentran  los  sintomas  clinicos  bien  marcados, 
mas  en  otros  estos  fueron  absentes.  Los  autores  con  de  la  opinion  que  la 
presencia  de  un  numero  tal  de  casos  de  tuberculosis  pulmonar,  debido  al 
contacto  directo  y  prolongado  con  las  personas  tuberculosas  en  el  hogar, 
demuestra  claramente  que  el  hogar  debe  ser  el  gran  campo  de  la  profilaxis 
en  la  eliminacion  de  la  tuberculosis.  No  solamente  el  paciente,  sino  tambien 
la  familia  deben  estar  bajo  una  observacion  directa  del  medico. 


La  transmission  et  le  progrfes  de  la  tuberculose  chez  les  enfants  par  les 
rapports  dans  la  famille. — (Floyd  et  Bowditch.) 

Ce  travail  consiste  dans  une  4tude  d'environ  900  enfants  gardes  en  ob- 
servation pendant  plusieurs  mois  a  I'Hopital  des  Poitrinaires  de  Boston. 
Les  cas  variaient  entre  quelques  mois  et  quinze  ans  d'age,  et  la  majorite 
avait  et6  expos^e  a  la  phtisie  pendant  une  6poque  variee  par  suite  de  la 
presence  de  cas  ouverts  dans  la  maison.  Au  moyen  d'examen  physique 
et  d'examen  du  sputum  r^p^t^s,  au  moyen  de  la  tuberculine  et  des  rayons 
X,  on  trouva  que  40  pour  cent  environ  avait  des  16sions  pulmonaires  d^finies 
et  26  pour  cent  environ  avaient  des  signes  ou  des  symptomes  ^vidents  de 
tuberculose.  Des  examens  de  la  gorge,  faits  dans  presque  tous  les  cas,  mon- 
trerent  dans  50  pour  cent  des  conditions  pr^judicial^les  h  la  respiration  nor- 
male.  Dans  un  grand  nombre  des  cas  les  symptomes  cliniques  aiderent  k 
faire  le  diagnostic,  mais  un  bon  nombre  n'avaient  absolument  aucun  mal. 
Les  auteurs  pensent  que  la  presence  d'un  si  grand  nombre  de  cas  montrant 
des  lesions  pulmonaires  d6finies,  quand  I'exposition  a  ^te  directe  et  prolong^e, 
ne  fait  qu'accentuer  le  fait  que  la  maison  est  le  champ  d'action  le  plus  vaste 
pour  les  mesures  prophylactiques  pour  controler  cctte  maladie.  Non  seule- 
ment  le  malade  mais  les  proches  parents  devraient  etre  soumis  h  un  strict 
examen  medical  pendant  cette  periode  d'exposition. 


ROLE   DE   LA  CONTAGION  HUMAINE   DANS   LA 
TUBERCULOSE  INFANTILE. 

Par  le  Dr.  J.  Comby, 

Paris. 


Laennec,  qui  devait  mourir  prematurement  phtisique,  nous  a  laisse  une 
admirable  description  anatomique  et  clinique  de  la  tuberculose.  De  son 
temps,  la  contagion  de  la  maladie  n'etait  soupgonnee;  mais  sa  frequence  dans 
certaines  families  avait  fait  croire  a  I'influence  pr^pond^rante  de  I'heredite, 
de  I'atavisrae. 

L'application  du  microscope  k  I'etude  des  lesions  anatomiques  ne  donna 
pas  tout  d'abord  les  fruits  qu'on  pouvait  esperer;  c'est  ainsi  que  Virchow  et 
I'ecole  allemande  s'egarerent  dans  la  doctrine  de  la  dualite  de  la  phtisie  que 
bientot  devait  combattre  victorieusement  Grancher  suivi  de  toute  I'ecole 
frangaise  (1873). 

Mais  deja  Villemin  (1865),  en  demontrant  experimentalement  I'inocula- 
bilite  de  la  matiere  tuberculeuse,  avait  ouvert  la  voie  aux  decouvertes  mod- 
ernes.  Koch,  qui  devoila  plus  tard  le  microbe  de  la  tuberculose  (1882),  fit 
eclater  la  valeur  des  recherches  geniales  de  Villemin. 

Villemin  et  Koch  ont  porte  le  dernier  coup  k  la  doctrine  de  I'heredite 
tuberculeuse.  De  la  contagiosite  de  la  maladie,  prouvee  experimentalement 
et  cliniquement  par  d'innombrables  travaux,  doivent  s'inspirer  toutes  les 
mesures  de  defense  individuelle  ou  collective  contre  la  tuberculose.  Sans 
nier  la  contagiosite  de  la  phtisie,  qui  est  I'evidence  meme,  certains  medecins 
croient  encore  a  la  transmission  hereditaire,  soit  du  germe,  soit  du  terrain 
propice  au  developpement  de  la  tuberculose:  heredite  de  graine,  heredite  de 
predisposition,  tels  sont  les  deux  termes  qui  r^sument  actuellement  la  doc- 
trine de  I'hereditd. 

On  a  vu,  chez  les  animaux  comme  dans  Tespece  humaine,  la  tuberculose 
se  transmettre  de  la  mere  au  fcctus  par  la  voie  placentaire;  cela  arrive  par- 
fois  quand  la  femme  enceinte  est  parvenue  a  un  degre  de  phtisie  tres  avanc^. 
De  cette  transmission  tuberculeuse  in  utcro,  on  connalt  quelques  observa- 
tions authentiques,  dont  MM.  Pehu  et  Chalier  ont  fait  le  compte  dans  un 
article  rdcent*. 

*  P6hu  et  Chalier:  "De  la  tuberculose  huraaiae  cong^nitale,"  Arch,  de  m6d. 
des  enfants,  Janvier,  1908. 

503 


504  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

II  r^sulte  de  la  statistique  tres  complete  etablie  par  eux,  que  I'her^dite 
de  graine  est  exceptionnelle  et  qu'on  peut  negliger  son  role  dans  I'etiologie 
de  la  tuberculose  de  I'enfance. 

Quant  a  I'her^dite  de  terrain,  autrement  dit  la  predisposition  heredi- 
taire,  elle  est  admise  par  un  grand  nombre  de  medecins.  On  croit  generale- 
ment  que  les  en  f ants  des  tuber culeux  naissent  avec  une  predisposition  a 
contracter  la  tuberculose.  Cette  erreur  est  enracinee  dans  beaucoup  d'esprits. 
Elle  est  d'ailleurs  basee  sur  des  faits  bien  observes  mais  mal  interpret^s. 

On  voit,  en  effet,  les  enfants  issus  de  families  tuberculeuses  etre  atteints 
dans  une  proportion  infiniment  sup^rieure  a  ceux  qui  proviennent  de  families 
indemnes. 

Mais  devons-nous  expliquer  par  I'her^dite  la  morbidite  et  la  mortality 
excessives  qui  deciment  ces  families  de  tuberculeux? 

II  n'est  plus  possible  de  soutenir  la  transmission  directe  du  bacille  de 
Koch  par  la  voie  placentaire,  Vheredite  de  graine;  on  se  contente  de  la  trans- 
mission organique  favorable  a  la  culture  du  bacille.  On  a  meme  pretendu 
reconnaitre  cette  predisposition  au  facies  et  a  1' habitus  exterieur  des  enfants: 
paleur,  maigreur,  etroitesse  de  la  poitrine,  adenopathies  souscutanees,  etc. 
Ces  stigmates  peuvent  s'observer  dans  les  families  tuberculeuses,  et  la  pre- 
disposition hereditaire  semble  ainsi  s'affirmer  en  traits  assez  saillants.  Mais 
I'habitus  exterieur  dont  nous  venons  d'esquisser  quelques  traits  n'est  pas 
special  aux  enfants  de  souche  tuberculeuse;  il  se  voit  chez  d'autres  enfants, 
issus  de  parents  sains,  et  qui  ont  ete  exposes  de  bonne  heure  a  une  contamina- 
tion etrangere  (nourrices,  gardeuses,  etc.). 

La  paleur,  la  maigreur,  I'etroitesse  thoracique,  la  micropolyadenopathie, 
sont  des  symptomes,  non  pas  de  predisposition,  mais  de  tuberculose  averee. 

Les  enfants  ainsi  conformes  ne  sont  pas  des  predisposes  a  la  tuberculose, 
des  pretuber culeux,  mais  bien  des  tuberculeux  latents.  En  d'autres  termes, 
ils  n'ont  pas  herit^  de  leurs  parents'  phtisiques  la  predisposition  a  contracter 
la  tuberculose;  mais  ils  ont  ete  contamines  par  eux  de  bonne  heure,  et  c'est 
pourquoi  ils  presentent  ce  faeies  particulier  qui  denote  une  tuberculose 
cachee.  Ce  n'est  ni  une  tuberculose  hereditaire,  ni  une  predisposition  here- 
ditaire, mais  bien  une  tuberculose  acquise  par  contagion  familiale. 

Grace  aux  proced^s  modernes  d'investigation  clinique,  la  cuti-reaction  a 
la  tuberculine  de  Von  Pirquet,  I'oculo-reaction  de  Wolff-Eissner  et  de  Cal- 
mette,  nous  pouvons  depister  les  tuberculoses  les  plus  secretes  et  montrer 
ainsi  que  ces  enfants  dits  predisposes  sont  en  realite  de  vrais  tuberculeux, 
et  il  est  facile  desormais  de  renverser  I'^difice  si  artificiel  et  si  fragile  de  la 
predisposition  her^chtaire. 

En  regie  g^nerale,  a  quelques  exceptions  pres,  la  tuberculose  des  parents 
ne  se  transmet  her^ditairement  aux  enfants  sous  aucune  forme,  et  I'heredite 
de  terrain  n'existe  pas  plus  que  I'heredite  de  graine.     Si  vous  eloignez,  le 


CONTAGION   HUMAINE   DANS   LA  TUBERCULOSE   INFANTILE. — COMBY.       505 

jour  meme  de  sa  naissance,  I'enfant  qui  vient  de  naitre  d'une  mere  phtisique 
au  dernier  degre,  pour  I'elever  hors  de  la  contagion  familiale,  dans  un  milieu 
indemne,  il  grandira  sain  et  robuste,  sans  devenir  tuberculeux;  done  il  n'a 
herite  ni  de  lagraine  ni  du  terrain.  S'il  reste  dans  son  milieu  familial  infecte, 
la  contagion  est  fatale,  et  tot  ou  tard  on  en  constatera  les  effets. 

Dans  ces  cas  de  tuberculose  familiale,  acquise  par  contagion,  I'oculo- 
reaction  ou  la  cuti-r^action  vont  nous  permettre  de  faire  une  selection  utile 
pour  le  traitement  et  pour  la  prophylaxie.  J'ai  vu,  dans  la  meme  famille, 
des  enfants  reagir  positivement  a  la  tuberculine,  alors  que  leurs  freres  et 
sceurs  ne  presentaient  aucune  reaction. 

Tantot  les  enfants  indemnes  avaient  vecu  loin  de  leurs  parents,  pendant 
que  ceux-ci  toussaient  et  crachaient  pres  des  freres  et  soeurs  restes  a  la  maison. 
Tantot  les  enfants  indemnes  etaient  nes  apres  la  guerison  d'une  tuberculose 
paternelle  ou  maternelle,  qui  n'avait  ete  funeste  qu'aux  premiers  n^s. 

Exemple:  Une  femme  d'une  trentaine  d'annees  a  eu  de  la  bronchite 
chronique  avec  hemoptysie,  il  y  a  quelques  annees :  elle  a  un  gargon  de  quatre 
ans  qui  reagit  positivement  a  la  tuberculine  et  un  b^be  de  six  mois  qui  ne 
reagit  pas.  C'est  que,  depuis  deux  ans,  ne  toussant  plus,  elle  a  cess^  d'etre 
dangereuse  pour  son  entourage. 

J'ai  cit6,  dans  un  m^moire  precedent  (Congr^s  de  la  tuberculose,  1905), 
des  cas  nombreux  de  contagion  familiale :  enfants  devenus  tuberculeux  apres 
un  contact  plus  ou  moins  prolonge  avec  les  phtisiques  de  leur  voisinage: 
pere,  mere,  grands-parents,  oncles  et  tantes,  nourrices  et  bonnes,  familiers 
de  la  maison,  etc.  De  tous  ces  faits,  bien  connus  aujourd'hui  et  dont  les 
m^decins  ont  pu  verifier  I'exactitude,  j 'avals  deja  tire  les  conclusions  au 
Congres  frangais  de  m^decine  r^uni  a  Montpellier,  en  1898.  Ces  conclusions, 
je  les  ai  developpees  dans  des  publications  ulterieures  et  je  demande  la  per- 
mission de  les  resumer.* 

Dans  1 'immense  majorite  des  cas,  la  tuberculose  infantile  derive  de  la 
contagion  familiale.  La  tul^erculose  des  enfants  ne  se  voit  que  dans  les 
families  tuberculeuses.  Vit-il  dans  un  milieu  indemne,  I'enfant  ne  se  tuber- 
culise  pas,  quel  que  soit  son  mode  d'alimentation.  La  tuberculose  des  en- 
fants ne  vient  pas  du  lait  qu'ils  consomment,  mais  des  bacilles  humains  qu'ils 
inhalent  ou  ingerent  dans  les  milieux  contamines  par  les  phtisiques. 

Tout  cela  peut  paraitre  trop  absolu  entach^  d'erreur  aux  yeux  de  beau- 
coup  de  m6decins,  et  je  vais  resumer  les  arguments  qui  plaident  en  faveur 
de  cette  doctrine. 

*  Dr.  J.  Comby:  "Tuberculose  pulmonaire  chcz  I'enfant,"  Arch,  do  m^tl.  des 
enfants,  mai,  1898;  "Tuberculose  chez  un  nourri.sson  de  cinquante-six  jours,"  ibid., 
sept.,  1900;  "Tuberculo.se  chcz  un  enfant  de  quarante  jours,"  ibid.,  f(5vrier,  1904; 
"Contagion  familiale  de  la  tuberculose  chez  I'enfant,"  ibid.,  nov.,  1905;  "Gouttes 
de  lait  et  tuberculo.se  infantile,"  ibid.,  mars,  1908;  "Oculo-r6action  k  la  tuberculine," 
Soc.  m6d.  des  hopitaux,  1907;  "Cuti-r^action,"  ibid.,  1908. 


506  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

Centre  la  transmission  par  le  lait  des  vaches  tuberculeuses,  on  peut  dire 
tout  d'abord  qu'il  n'y  a  pas  identity  entre  le  bacille  bovin  et  le  bacille  humain. 
Mais,  en  admettant  qu'il  y  ait  identity  de  nature  et  d'origine  entre  ces  deux 
bacilles,  on  sera  surpris  que  la  tuberculose  infantile  n'ait  pas  diminue  mal- 
gre  les  mesures  severes  prises  depuis  plus  de  vingt  ans  contre  les  vaches 
tuberculeuses  et  contre  leur  lait. 

On  a  fait  beaucoup  de  bruit  autour  de  la  tuberculose  des  bovides,  on  a 
partout  souligne  le  danger  de  consommer  leur  viande  et  leur  lait.  II  en 
resulte  que : 

1.  On  a  elimin^  le  plus  possible  les  vaches  tuberculeuses  des  stables  de 
la  ville  ou  de  la  campagne;  grdce  a  la  tuberculine  de  Koch,  la  selection  est 
devenue  facile,  et  elle  est  employee  couramment  dans  les  fermes  importantes 
et  les  vacheries  bien  tenues  et  surveillees; 

2.  On  a  pris  I'habitude  de  faire  bouillir  ou  de  steriliser  le  lait  destine  aux 
nourrissons,  et  quelle  que  soit  sa  provenance;  le  chauffage  du  lait  tue  tous 
les  microbes  qu'il  pourrait  contenir;  le  lait  cru  n'6tant  prescrit  qu'excep- 
tionnellement,  il  devient  bien  difficile,  aux  enfants  de  se  contaminer  par 
le  lait. 

Supposons  que  cette  double  pratique  de  la  selection  des  vaches  et  de  la 
sterilisation  de  leur  lait  ne  soit  pas  generale;  que  les  vaches  tuberculeuses 
continuent  a  fournir  du  lait  a  la  consommation  infantile,  que  les  parents 
negligent  de  steriliser  le  lait  destine  a  leurs  enfants.  En  r^sultera-t-il  un 
danger  s6rieux,  un  risque  redoutable  de  propagation  tuberculeuse?  Pour 
qu'un  lait  soit  vraiment  dangereux,  il  doit  etre  souille  de  nombreux  bacilles 
de  Koch,  ce  qui  se  voit  surtout  dans  les  cas  de  mammite  tuberculeuse. 
S'il  n'en  contient  qu'un  petit  nombre,  il  passera  impunement  par  la  voie 
digestive  sans  infecter  I'enfant. 

On  a  dit  cependant  le  contraire,  et  des  savants  de  premier  ordre  ont  ainsi 
jete  le  trouble  dans  les  esprits.  Le  professeur  Von  Behring  soutient  que  la 
tuberculose  se  transmet  tou jours  par  le  lait  de  vache  et  que  la  porte  d 'entree 
exclusive  du  bacille  de  Koch  est  le  tube  digestif.  Sans  etre  aussi  exclusifs, 
les  savants  exp6rimentateurs  fran^ais,  Vallee  (d'Alfort),  Calmette  (de 
Lille),  ont  accorde  ^  la  voie  intestinale  un  role  tres  important  et  fait  a  la 
contagion  par  le  lait  une  place  trop  grande. 

Sans  parler  des  experiences  contradictoires  de  Fliigge,  de  Kuss  et  Lob- 
stein,  etc.,  la  clinique  infantile  donne  un  dementi  aux  conclusions  de  Behring, 
Vallee  et  Calmette. 

Comme  je  I'ai  dit  en  1898,  comme  je  I'ai  r^pet^  depuis  lors  maintes  et 
maintes  fois,  comme  I'ont  vu  les  m^decins  d'enfants  de  tous  les  pays  (Medin 
entre  autres),  la  tuberculose  des  enfants  derive  uniquement  de  la  contagion 
humaine,  de  la  tuberculose  ouverte  de  leurs  farmiliers  ou  de  leurs  proches 
(parents,  domestiques,  amis  de  la  maison).     Les  faits  d'observation  a  Tap- 


CONTAGION   HUMAINE   DANS   LA   TUBERCULOSE   INFANTILE. — COMBY.       507 

pui  de  cette  doctrine  clinique  sont  innombrables;  ils  se  v^rifient  chaque  jour 
dans  la  pratique  medicale. 

La  tuberculose  des  enfants  ne  se  voit  que  dans  les  families  tuberculeuses; 
la  ou  vivent  des  adultes  tuberculeux,  on  trouvera  des  enfants  tuberculeux; 
la  ou  il  n'y  en  a  pas,  on  n'en  trouvera  pas.  Tous  les  enfants  des  milieux 
populaires  ou  nous  avons  recueilli  la  plupart  de  nos  observations  boivent  le 
meme  lait,  regoivent  la  meme  alimentation;  les  seuls  qui  deviennent  tuber- 
culeux sont  ceux  qui  se  trouvent  exposes  k  la  contagion  humaine. 

Done  le  lait  ne  compte  pas,  le  phtisique  seul  est  a  redouter.  Je  vais  avoir 
recours  maintenant  a  un  argument  d'ordre  anatomique. 

Les  autopsies  que  j'ai  faites  dans  les  hopitaux  d'enfants,  depuis  quatorze 
ans,  montrent  I'accroissement  de  la  tuberculose  avec  I'age.  Rare  dans  les 
premiers  mois  de  la  vie,  la  tuberculose  augmente  rapidement  de  frequence 
dans  les  premieres  annees  et  la  seconde  enfance.  Les  lesions  les  plus  con- 
stantes  et  les  plus  anciennes  semblent  groupees  autour  de  la  trachee  et  des 
bronches,  et  I'adenopathie  tracheo-broncliique  semble  etre  comme  le  pivot 
de  toutes  les  localisations  tuberculeuses  infantiles;  cette  localisation  initiale 
temoigne  en  faveur  de  la  porte  d'entree  aerienne.  Je  n'ai  jamais  observe 
de  tuberculose  primitive  de  I'intestin. 

Sur  un  total  de  1432  autopsies,  j'ai  releve  la  tuberculose  529  fois  (soit 
pres  de  37  pour  cent);  dans  tous  ces  cas,  j'ai  trouve  des  ganglions  infiltres, 
caseeux  ou  cretaces  autour  des  bronches;  les  lesions  des  poumons,  des  men- 
inges, du  foie,  de  la  rate,  de  I'intestin,  des  ganglions  m^senteriques,  se  sont 
montrees  beaucoup  moins  frequentes  que  la  tuberculose  des  ganglions 
tracheo-bronchiques. 

La  proportion  des  tuberculeux  varie  beaucoup  suivant  I'dge  des  enfants. 
Sur  216  autopsies  d'enfants  de  moins  de  trois  mois,  je  n'ai  releve  que  4  tuber- 
culeux (moins  de  2  pour  cent) ;  ces  4  cas  s'expliquaient  par  la  contagion 
maternelle,  non  par  1' alimentation. 

Sur  1008  autopsies  d'enfants  n'ayant  pas  d^pass^  deux  ans,  on  compte 
252  tuberculeux,  soit  pres  de  25  pour  cent.  Si  Ton  ne  prend  que  les 
enfants  entre  un  et  deux  ans,  au  nombre  de324,  on  trouve  140  tuberculeux 
(43  pour  cent).  Entre  zero  et  un  an,  sur  684  enfants,  nous  en  trouvons 
112  tuberculeux  (un  peu  plus  de  16  pour  cent).  Entre  trois  et  six  mois, 
sur  216  autopsies,  39  tuberculeux  (18  pour  cent);  entre  six  et  douze  mois, 
sur  254  autopsies,  69  tuberculeux  (27  pour  cent).  Apres  la  seconde  annee, 
la  proportion  des  tuberculeux  atteint  67  pour  cent. 

De  cette  augmentation  rapidement  ascendante  de  la  tuberculose  h  mesure 
qu'on  s'eloigne  de  la  premiere  enfance,  de  I'age  ou  le  lait  forme  la  nourri- 
ture  exclusive  ou  principale,  on  pourrait  deja  conclure  que  le  lait  n'est  pas 
le  vehicule  habituel  de  la  maladie.  L'enfant  a  beau  consommer  du  lait  en 
abondance,  il  ne  dcvient  que  rarement  tuberculeux;  apres  le  sevrage,  quand 


508  SIXTH   INTERNATIONAL  CONGRESS   ON   TUBERCULOSIS, 

sa  ration  de  lait  est  r^duite  au  minimum,  ses  chances  de  tuberculisation 
augmentent.     Qu'est-ce  a  dire? 

Tout  petit,  couche  dans  un  berceau  ou  porte  sur  les  bras,  Ic  nourrisson 
vit  dans  un  isolement  relatif  et  ne  participe  que  dans  une  faible  mesure  a  la 
vie  commune  si  feconde  en  contagions  de  toute  sorte.  II  est  ainsi  protege 
contre  la  tuberculose  des  foules  et  des  collectivites  banales.  Mais,  si  la  tuber- 
culose  pulmonaire  est  dans  sa  famille;  s'il  est  visite,  embrass4,  caress^,  en- 
tour6  par  des  parents  tuberculeux  qui  toussent  et  crachent  autour  de  lui, 
alors  il  est  condamn6  a  I'infection  tuberculeuse,  il  ne  saurait  y  echapper. 
II  y  6chappe  d'autant  moins  qu'il  est  plus  avance  en  age,  les  chances  de  con- 
tamination se  multipliant  avec  les  ann^es. 

Si  le  lait  etait  la  cause  principale  de  la  tuberculose  infantile,  c'est  pendant 
I'allaitement,  dans  la  premiere  ann^e,  qu'on  devrait  rencontrer  le  plus  de 
tuberculeux;  c'est  alors  qu'on  en  trouve  le  moins. 

Apres  une  pratique  de  la  medecine  infantile  qui  depasse  vingt-cinq  ans 
(onze  ans  au  dispensaire  d'enfants  de  la  Society  philantropique,  quatorze 
ans  dans  les  hopitaux  d'enfants  de  Paris),  je  declare  n'avoir  pas  vu  un  seul 
cas  de  tuberculose  infantile  cause  par  le  lait,  tandis  que  j'ai  par  centaines 
relev^  les  cas  de  contagion  humaine.  Toutes  les  modalit^s  de  cette  con- 
tagion ont  ete  exposees  dans  mon  memoire  du  Congres  de  Paris;  je  n'y  re- 
viendrai  pas. 

L'histoire  de  la  tuberculose  infantile  s'expHque  merveilleusement  bien 
par  la  contagion  humaine,  surtout  par  la  contagion  familiale,  dont  les  preuves 
anatomo-cliniques  surabondent.  EUe  devient  obscure,  sinon  incompre- 
hensible, avec  I'origine  bovine  et  la  transmission  par  le  lait  des  animaux 
tuberculeux.  La  prophylaxie  inspiree  par  cette  derniere  doctrine,  et  qui 
s'est  traduite  par  la  surveillance  des  viandes  de  boucherie,  par  la  selection 
des  vaches  laitieres,  par  la  sterilisation  du  lait,  n'a  absolument  rien  donn6. 
Loin  de  reculer  devant  ces  mesures  d'hygiene,  d'ailleurs  parfaitement  recom- 
mandables,  la  tuberculose  infantile,  comme  le  montre  ma  statistique 
hospitaliere,  est  au  moins  aussi  frequente  que  par  le  passe. 

C'est  que  ni  la  viande  ni  le  lait  ne  sont  coupables.  Sans  doute,  il  faut 
faire  bouillir  son  lait,  sans  doute  il  est  prudent  de  repousser  la  viande  qui 
provient  d'animaux  tuberculeux,  ou  tout  au  moins  de  la  steriliser  par  la 
chaleur.  Mais,  quand  on  aura  fait  cela,  c'est  comme  si  Ton  n'avait  rien  fait. 
Toutes  les  precautions  prises  contre  les  vaches  ou  contre  leur  lait  sont  ab- 
solument vaines,  si  Ton  n'a  pas  pu  proteger  I'enfant  contre  la  contagion  hu- 
maine, la  seule  qui  compte  en  pratique.  S'il  continue  a  vivre  avec  un  phtis- 
ique  qui  tousse  et  crache,  I'enfant  est  fatalement  atteint  de  tuberculose. 
Voil^  ce  qu'on  doit  bien  savoir,  ce  qu'on  ne  saurait  trop  r6p6ter. 

D6fions-nous  des  adultes  et  surtout  des  vieillards  qui  toussent  et  crach- 
ent, des  grands-parents  qu'on  declare  atteints  depuis  longtemps  d'asthme, 


CONTAGION   HUMAINE   DANS   LA   TUBERCULOSE   INFANTILE. — COMBY.      509 

de  catarrhe,  d'emphyseme,  de  bronchite  chronique;  ce  sont  autant  de  tuber- 
culeux,  parfois  de  bonne  apparence,  sans  fievre,  sans  cachexie.  J'ai  vu  de 
nombreux  enfants  mourii-  de  meningite  tuberculeuse  pour  ne  pas  avoir  ete 
soustraits  en  temps  opportun  aux  caresses  de  leurs  grands-parents.  De- 
fions-nous  des  vieux  diabetiques  qui  maigrissent  et  se  mettent  a  tousser. 
Surveillons  les  parents,  les  amis,  les  familiers  de  la  maison,  les  nourrices,  les 
bonnes,  les  domestiques,  les  maitres  d'ecole,  en  un  mot  tous  ceux  que  leurs 
liens  de  parente,  leurs  relations,  leurs  fonctions  retiennent  aupres  des  enfants. 

Pensons  tou jours  et  avant  tout  a  la  tuber culose,  au  danger  formidable 
qu'elle  fait  courir  aux  jeunes  sujets.  Cette  preoccupation  constante  des 
medecins  et  des  families  pr^parera  le  terrain  a  la  prophylaxie  antitubercu- 
leuse. 

En  semant  la  terreur  d'un  mal  si  souvent  inexorable,  on  fera  adopter  par 
les  families  des  mesures  qui  froissent  parfois  des  sentiments  respectables, 
mais  qui  doivent  etre  prises  neanmoins  dans  I'interet  superieur  des  enfants. 

II  faut  qu'on  le  sache  bien  une  fois  pour  toutes:  la  tuberculose  n'est  pas 
h^reditaire,  les  enfants  ne  naissent  pas  tuberculeux,  ils  le  deviennent.  Nous 
pouvons  les  preserver  de  la  contagion,  done  nous  le  devons.  L'her^dite  n'ex- 
iste  a  aucun  degre  ni  sous  aucune  forme;  les  enfants  de  tuberculeux  n'ap- 
portent,  en  naissant,  ni  le  germe  ni  la  predisposition. 

Defendons-les  contre  la  contagion  de  leurs  proches,  et  nous  les  sauverons. 
La  tuberculose  ne  se  transmet  jamais  aux  enfants  par  le  lait  des  vaches  tuber- 
culeuses  qu'ils  sont  exposes  a  boire;  elle  derive  toujours  de  la  contagion  hu- 
maine,  particulierement  de  la  contagion  familiale. 

Done  la  prophylaxie  ne  fera  ceuvre  vraiment  utile  que  si  elle  empeche  les 
contacts  entre  les  adultes  tuberculeux  et  les  enfants  sains.  Si  ces  contacts 
ont  pu  deja  s'exercer  dans  I'ignorance  ou  Ton  etait  de  la  nature  du  mal,  il 
est  urgent  d'y  mettre  un  terme.  Et  la  prophylaxie  doit  se  borner  alors  a 
prevenir  les  ech^ances  funestes  d'une  tuberculose  latente  contractee  au  foyer 
familial.  De  ce  foyer  toujours  infecte,  il  faut  eloigner  les  enfants;  c'est  ce 
qu'avait  admirablement  compris  Grancher  quand  il  crea  son  (Euvre  de  pre- 
servation de  I'enfance  contre  la  tuberculose. 

Cette  oeuvre,  en  plcine  prosperity  aujourd'hui,  assure  aux  enfants  pauvres 
des  families  tuberculeuses  un  sejour  prolonge  a  la  campagne,  chez  des  pay- 
sans  indemnes,  surveilles  par  des  mddecins  affilies  a  I'oeuvre.  Le  retour  a 
la  terre,  la  vie  rurale,  le  travail  des  champs,  voila  ce  qui  sauvera  la  graine  des 
generations  futures. 

Pour  instituer  ce  traitement  pr^ventif  des  tuberculoses  contract^es  k  la 
ville  et  que  la  campagne  gu^rira,  il  convient  de  faire  appel  aux  nouveaux 
procedds  de  depistage  de  la  tuberculose,  Toculo-r^action  de  Wolff-Eisner  et 
Calmette,  la  cuti-r^action  de  Von  Pirquet. 

Ces  moyens,  inoffensifs  et  d'une  application  facile,  sont  appel^s  k  rendre 


510  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

de  grands  services  dans  la  medecine  des  enfants.  lis  m'ont  permis  de  faire 
a  coup  stir,  dans  les  families,  la  selection  des  enfants,  et  par  suite  de  bien 
diriger  les  efforts  de  la  prophylaxie  antituberculeuse. 


Menschliche  Ansteckung  als  ein  Factor  in  Kindertuberkulose. — (Comby.) 

Uie  Ubertragung  von  Koch's  Bazillus  von  der  Mutter  auf  das  Kind 
durch  die  Placenta  ist  ausnahmsweise,  noch  ist  der  Boden  irgendwie  mehr 
ererbt  als  der  Same.  Es  ist  kein  Zweifel,  dass  tuberkulose  Eltern  Tuber- 
kulose  auf  ihre  lender  iibertragen,  aber  wenn  sie  es  thun,  dann  ist  es  durch 
Beriihrung.  Die  Beriihrung  in  der  Familie  erklart  fast  alle  Fiille  von  Kin- 
dertuberkulose. Ubertragung  durch  die  Milch  und  das  Fleisch  tuberkuloser 
Kiihe  spielt  eine  sehr  wenig  wahrnehmbare  Rolle  in  der  Ubertragung  der 
Krankheit  auf  die  species  humana.  Das  Kind  kann  gegen  diese  Gefahr 
durch  eine  richtige  Auswahl  der  Kiihe  und  durch  Sterilisation  der  Milch 
vollstandig  geschiitzt  werden. 

Unsere  klinischen  Forschungen  haben  gezeigt,  dass  tuberkulose  Kinder 
nur  in  Familien  mit  tuberkulosen  Mitgliedern  gefunden  werden,  gleich- 
giiltig,  welche  Art  von  Milch  consumirt  wird.  Andererseits  finden  wir 
bei  Autopsieen  Tuberkulose  der  peribronchialen  Driisen,  welche  daher  den 
Luftweg  des  Eintrittes  des  Koch'schen  Bazillus  darstellen. 

Unter  1432  Autopsieen  von  Kindern  von  den  Pariser  Hospitiilern  im 
Laufe  von  vierzehn  Jahren  fand  ich  529  tuberkulose  Falle,  oder  ungefahr 
37%;  unter  216  Kindern  von  0  zu  3  Monaten  4  tuberkulose,  oder  weniger 
als  2%;  unter  1008  von  0  zu  2  Jahren  252  tuberkulose,  oder  ungefahr  25%. 

Nach  dem  zweiten  Jahre  erreicht  das  Verhaltnis  tuberkuloser  Cadaver 
45,  50,  60  und  65%.  All  dies  ist  vollstandig  durch  menschliche  Ansteck- 
ung erklart. 

Die  Prophylaxis  sollte  sich  mit  phthisischen  menschlichen  Wesen  und 
nicht  mit  Kiihen  beschaf  tigen. 


Human  Contagion  as  a  Factor  in  Infantile  Tuberculosis. — (Comby.) 

Transmission  of  Koch's  bacillus  from  the  mother  to  the  fetus  by  way 
of  the  placenta  is  exceptional,  nor  is  the  soil  inherited  any  more  than  the 
seed.  There  is  no  doubt  that  tuberculous  parents  transmit  tuberculosis 
to  their  children;  but  when  they  do,  it  is  through  contagion.  Family  con- 
tagion explains  almost  all  cases  of  infantile  tuberculosis.  Transmission 
through  the  milk  or  flesh  of  tuberculous  cows  plays  a  very  insignificant 
part  in  the  transmission  of  the  disease  to  the  human  species.     The  infant 


CONTAGION   HUMAINE   DANS   LA   TUBERCULOSE   INFANTILE. — COMBY.       511 

can  be  fully  protected  against  this  danger  by  a  proper  selection  of  cows 
and  sterilization  of  the  milk. 

Our  clinical  investigations  have  shown  that  tuberculous  children  are 
found  only  in  families  in  which  there  are  tuberculous  members,  regardless 
of  the  kind  of  milk  consumed.  On  the  other  hand,  we  constantly  find 
at  autopsies  tuberculosis  of  the  peribronchial  glands,  which  therefore 
represent  the  aerial  port  of  entry  of  the  bacillus  of  Koch.  Among  1432 
autopsies  on  children  from  the  hospitals  of  Paris  during  the  course  of 
fourteen  years,  I  found  529  tuberculous  subjects,  or  about  37%;  among 
216  infants  from  0  to  3  months,  4  tuberculous,  or  less  than  2%;  of  1008 
from  0  to  2  years,  252  tuberculous,  or  about  25%. 

After  the  second  year,  the  proportion  of  tuberculous  cadavers  attains 
45,  50,  60,  and  65%.     All  this  is  fully  explained  by  human  contagion. 

Prophylaxis  should  occupy  itself  with  phthisical  human  beings  and  not 
with  cows. 


El  Contagio  humano  como  factor  en  la  Tuberculosis  Infantil. — (Comby.) 

La  trasmision  del  bacilo  de  Koch  de  la  madre  al  feto  por  medio  de  la 
placenta  es  excepcional.  No  hay  duda  que  la  tuberculosis  de  los  padres 
puede  ser  trasmitida  a  sus  hijos,  mas  en  este  caso  la  infeccion  es  por  medio 
del  contagio.  El  contagio  de  la  familla  explica,  en  casi  todos  los  casos,  la 
tuberculosis  infantil.  La  trasmision  por  medio  de  la  leche  6  carnes  de 
animales  tuberculoses  puede  ser  posible,  mas  esta  es  de  poca  significacion 
en  la  trasmision  de  la  enfermedad  a  la  especie  humana.  Los  niiios  pueden 
ser  enteramente  protegidos  contra  este  peligro  por  medio  de  la  seleccion  de 
las  vacas  y  la  esteriUzacion  de  la  leche. 

Nuestras  observacions  han  demostrado  que  nifios  tuberculoses  se  encuen- 
tran  solamente  en  las  famiUas  en  donde  un  miembro  de  ella  padece  de  la 
enfermedad,  y  que  la  calidad  de  leche  usada  por  la  familia  no  tiene  gran 
importancia.  Por  otra  parte  constantemente  se  encuentra  en  las  autopsias 
tuberculosis  de  las  glandulas  peribronquiales,  las  cuales  presentan  la  puerta 
aerea  para  la  entrada  del  bacilo  de  Koch.  Do  1432  autopsias  hechas  en  el 
hospital  de  Paris  durante  el  perfodo  de  14  afios,  yo  encontre  521  personas 
tuberculosas  6  sea  37%  de  los  casos;  De  216  ninos  de  0  a  3  meses  de  edad, 
cuatro  tuberculoses,  6  sea  menos  de  2% ;  entre  1008  de  0  a  2  anos  de  edad, 
252  tuberculoses  6  sea  un  25%. 

Despu^s  de  des  anos  de  edad,  la  proporcion  de  les  cadaveres  tubercu- 
loses fue  de  45,  50,  60  y  65%.  Todo  esto  se  explico  perfectamente  por  medio 
del  contagio  humano. 

Las  medidas  profilaticas,  per  lo  tanto,  deben  ser  dirigidas  hacia  el 
hember  y  no  hacia  los  animales,  particularmente  la  vaca. 


512  SIXTH  INTERNATIONAL    CONGRESS   ON   TUBERCULOSIS. 

DISCUSSION. 

Dr.  Woods  Hutchinson  (New  York) :  The  findings  of  the  valuable  papers 
that  have  just  been  read  strike  me  with  dismay.  Tuberculosis  is  evidently 
much  more  frequent  in  children  than  is  usually  supposed.  We  have  been 
overlooking  the  cases  that  recovered,  just  as  we  did  in  adults  ten  years  ago. 
Yet  this  gives  a  definite  point  at  which  to  strike  the  known  consumptive 
and  the  rooms  in  which  he  lives,  just  as  in  malaria  we  struck  at  the  pool  in 
wliich  the  anopheles  breeds.  Cover  this  ground,  and  we  can  then  hope  to 
lower  the  present  70  per  cent,  of  tuberculosis.  The  second  striking  point 
is  the  marked  frequency  of  pulmonary  lesions — more  than  5  per  cent,  of  the 
glandular,  and  less  than  1  per  cent,  of  bone  and  joint  lesions. 

It  would  look  as  if  these  latter  forms  were  secondary  to  a  pulmonary 
invasion.  Certainly  the  large  preponderance  of  bone  and  glandular  tuber- 
culosis in  cliildren  in  the  older  statistics  was  due  to  their  easy  recognition, 
while  the  pulmonary  forms  escape. 

Dr.  Rist  (Paris,  France) :  There  is  a  new  scheme  of  prophylaxis  that  was 
brought  out  by  Professor  Grancher,  of  Paris.  From  the  fact  that  children 
always  are  infected  by  tuberculous  parents  or  other  tuberculous  members 
of  the  family  he  came  to  the  conclusions  to  take  the  still  healthy  cliildren 
to  a  place  where  they  can  be  protected  from  tuberculous  infections;  200 
children  were  taken  away  from  their  families  and  reared  in  the  country  or  on 
farms. 

The  first  condition  is  a  very  careful  selection  of  the  children,  and  only  an 
entirely  healthy  child  should  be  taken  from  the  family.  There  is  a  special 
medical  committee  appointed  for  this  purpose.  The  children  are  sent  to 
country  places,  thus  increasing  the  number  of  children  who  will  escape  from 
tuberculous  infections.  This  work  was  not  begun  on  a  large  scale,  the  cost 
being  very  low  in  France — almost  one  franc  a  day  a  child.  In  a  wealthy 
country  like  the  United  States  it  should  be  very  easy  to  follow  out  tliis 
scheme  on  a  greater  scale. 

Dr.  H.  S.  Goodall  (New  York)  believes  that  an  attack  on  tuberculosis 
in  children  is  important,  because  we  may  stamp  out  tliis  disease  while  the 
child  is  still  young,  and  because  the  child  will  teach  others  how  to  live  after 
he  has  himself  been  taught;  that  the  physical  signs  are  not  like  those  in 
adults,  but  are  atypical,  as  have  been  described;  that  a  point  on  the  an- 
terior axillary  line  at  the  third  space  or  fourth  rib  is  a  frequent  seat  of  ab- 
normal signs;  that  the  area  of  lung  tissue  involved  and  the  degree  of  temperature 
found,  being  equal  to  that  in  cases  of  adults,  the  immediate  results  are  better 
in  the  children  under  ten  years  of  age,  and  the  permanent  results,  as  far  as 
may  be  judged  after  five  years*  observation,  are  certainly  as  good,  if  not 
better,  than  in  adults.  The  records  of  Stony  Wold  Sanatorium  bear  out 
this  statement. 


CONTAGION   HUMAINE   DANS   LA   TUBERCULOSE   INFANTILE. COMBY.       513 

Dr.  Herbert  Decarle  Woodcock  (Leeds,  England)  stated  that  he 
would  like  to  remind  the  members  that  natural  immunity  is  obtained  only 
by  contact  with  disease,  not  by  isolation  from  disease. 

The  Anti-tuberculous  Society  of  Trinidad  has  recognized  this  in  a 
brightly  written  report  in  which  it  is  stated  that  the  "  African  fresh  from 
his  forest  bed  of  leaves  dies  if  brought  into  close  contact  with  the  disease," 
when  the  white  man  of  old  civilization  does  not  succumb.  The  Irishman, 
living  away  from  cities,  dies  when  introduced  to  city  Hfe.  The  Jew,  the 
ancient  race  which  has  been  forced  by  tyranny  to  live  in  slums  for  more  than 
one  thousand  years,  is  now  much  more  immune  to  the  disease  than  is  the 
case  with  other  races;  yet  if  the  Jew  is  introduced  to  conditions  worse  than 
he  has  been  accustomed  to,  he  succumbs. 

In  Leeds,  England,  there  are  30,000  Jews;  they  have  the  worst  dwellings 
in  the  city — ^the  parts  of  the  city  refused  by  the  English  artisan.  They  con- 
fine themselves  to  the  clothing  trade,  a  trade  dusty,  unhealthy,  carried 
out  often  under  unsanitary  conditions,  causing  phthisis  among  all  races  en- 
gaged in  it. 

The  immunity  of  the  Jew  to  phthisis  has  broken  down  to  some  extent  in 
Leeds.  Yet  with  all  this  the  Jew  is  superior  in  health  record  and  in  physique 
to  the  Gentile  in  the  same  state  of  life,  i.  e.,  in  Leeds.  This  superiority  of 
physique  is  especially  noticeable  in  the  young. 

He  examined  a  school  a  few  weeks  ago,  and  finds  one-half  with  the  Cal- 
mette  reaction.  All  these  children  have  defects  in  nose  and  throat.  In  an 
English  artisan  club  he  finds  a  large  number  of  defects  in  nose  and  throat 
and  teeth  among  the  members.  He  examines  the  same  number  of  Jewish 
club  members  (80  in  each  club)  and  does  not  find  the  defects  in  nose,  throat, 
and  teeth.  Only  the  general  results  show  that  the  more  immune  race  had 
the  normal  nose  and  throat;  the  Jewish  palate  (hard)  is  dome-shaped,  for 
instance. 

In  conclusion  he  said  that  if  you  isolate  people  from  unsanitary  surround- 
ings, you  must  supply  an  artificial  immunity  to  take  the  place  of  the  natural 
immunity  obtained  by  the  eUmination  of  the  unfit.  In  all  the  splendid 
philanthropy  of  our  country  we  must  remember  this,  otherwise  by  complete 
isolation  of  peoples  we  shall  retrograde  in  immunity. 

Dr.  Bovaird  (New  York)  calls  attention  to  the  fact,  as  borne  out  by 
the  paper  of  La  F4tra  on  the  opening  day,  that  there  are  no  typical  or  char- 
acteristic physical  signs  of  tuberculosis  in  children.  Physical  signs  taken 
alone  should  not  be  accepted  as  evidence  of  tuberculosis. 

The  use  of  tuberculin  as  a  test,  in  the  conjunctiva,  in  the  skin,  or  subcu- 
taneously,  is  evidently  of  great  value  in  diagnosis,  and  is  unquestionably 
enabling  us  to  classify  as  definitely  tuberculous  many  children  who,  under 
previous  conditions,  have  passed  as  sound. 

VOL.  n — 17 


514  SIXTH   INTERNATIONAL   CONGRESS    ON   TUBERCULOSIS, 

It  is  a  question  whether  tuberculosis  of  children  leads  on  directly  to  that 
of  adult  life.  In  pathological  work  it  is  well  known  that  tuberculosis  of 
children  shows  its  most  advanced  lesion  in  the  cervical,  bronchial,  or  mesen- 
teric glands  in  80  per  cent,  of  cases.  In  adult  tuberculosis  this  is  not  at  all 
true;  in  fact,  a  similar  localization  of  the  lesion  is  quite  rare.  It  is,  therefore, 
a  debatable  question  whether  one  is  directly  concerned  in  the  evolution  of 
the  other,  and  to  what  degree.  Finally,  this  matter  was  not  one  of  diagno- 
sis, but  of  management.  Many  of  these  patients  have  only  a  latent  tubercu- 
losis, and  require  no  treatment  at  the  time.  All  such  cases  do,  however, 
call  for  careful  supervision  and  active  measures  in  case  of  development  of 
any  symptoms  suggestive  of  advance  in  the  disease. 

Dr.  Hamill  (Philadelphia)  said  that  in  work  of  this  character  we  must 
be  careful  to  interpret  the  physical  signs  correctly.  He  recently  examined 
300  children  in  an  institution  and  could  find  but  12  cases  in  which  he  could 
definitely  make  the  diagnosis  of  pulmonary  tuberculosis.  Two  signs  on 
which  emphasis  is  laid  are  very  misleading,  i.e.,  areas  of  diminished  reso- 
nance and  of  diminished  breathing.  Such  signs  can  be  developed  by 
mere  change  of  position,  i.  e.,  from  side  to  side  of  the  child,  the  resulting 
pressure  so  changing  the  signs.  The  diagnosis  of  tuberculosis  from  such 
signs  should  be  questioned. 

In  his  use  of  the  conjunctival  and  subcutaneous  tests  with  tuberculin  he 
finds  a  very  remarkable  uniformity  of  results.  This  being  true,  he  thinks 
it  important  to  eliminate  the  conjunctival  test,  by  reason  of  the  danger 
attendant  upon  its  use. 

Dr.  Jacobi  (New  York)  said  that,  no  doubt,  pulmonary  tuberculosis  as 
seen  in  adult  life  is  not  very  frequent  in  children.  We  hear  of  pro- 
phylaxis, but  not  a  single  word  on  treatment.  We  practitioners  do  not 
deal  with  tuberculosis  by  the  one  thousand  or  million  patients,  but  we 
treat  the  individual.  What  can  be  done  in  the  way  of  individual  treat- 
ment? That  is  the  responsibiUty  of  the  practitioner  to  the  patient.  We 
are  told  that  we  cannot  treat  tuberculosis.  We  are  told  to  use  fresh  air, 
good  food,  good  clothing,  etc.  That  is  the  line  of  treatment,  just  as  much  as 
the  use  of  bismuth  is  recommended  in  enteritis  or  baths  in  typhoid  fever. 
A  night's  restlessness  may  undo  weeks  of  good  air,  good  food,  good  clothing. 
A  dose  of  morphin  relieves  and  prevents  that  result  and  is  good  treatment. 
Digitalis,  spartein,  etc.,  may  be  used  to  help  the  circulation,  and  will  do 
the  patient  good.  Digitalis,  two,  three,  or  four  grains  a  day,  may  be  given 
for  prolonged  periods  with  benefit.  We  may  give  abundance  of  food  without 
result  unless  we  give  a  little  bismuth  and  pepsin  to  help  the  feeble  diges- 
tion. The  usual  way  for  sanatoriums  to  treat  tuberculous  patients  with- 
out medicine  is,  as  a  matter  of  fact,  defective. 


SECTION  IV. 


Tuberculosis  in  Children — Etiology,  Prevention, 
and   Treatment   {Continued), 


THIRD  DAY.    AFTERNOON  SESSION. 

Wednesday,  September  30,  1908. 

ABNORMALITIES  OF  THE    NASOPHARYNX.    TUBERCULOSIS    AND 

CONFINED  AIR.    PLACENTAL  TRANSMISSION.    SCHOOL 

HYGIENE  IN  ECUADOR. 


The  President,  Dr.  Jacobi,  called  the  Section  to  order  at  three  o'clock. 


OBSTRUCTIVE   ABNORMALITIES   OF  THE  NOSE  AND 

THROAT: 

PREDISPOSING  FACTORS  TO  TUBERCULOSIS  IN  SCHOOL 

CHILDREN. 

By  Dr.  John  J.  Cronin, 

New  York. 


The  high  percentage  of  abnormalities  of  the  nose,  throat,  and  pharyngeal 
spaces,  found  among  children  of  school  age  from  homes  of  the  tuberculous, 
indicates  that,  whatever  may  be  the  reason  of  the  abnormal  development  of 
lymphoid  tissue  and  deformities,  their  presence  induces  a  lessened  resistance 
against  the  constant  exposure  to  tuberculosis.  Whether  or  not  there  is 
some  one  underlying  factor  that  results  invariably  in  tuberculosis  cannot  be 
stated.  It  is  certain  that  these  factors  which  operate  against  dull  growth 
and  development,  if  combined  with  exposure  to  the  disease,  result  in  some 
form  of  tubercular  manifestation.    The  conditions  of  exposure  being  equal, 

615 


516 


SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 


the  chances  of  acquiring  the  disease  are  greater  in  those  whose  head  cavities 
are  abnormal;  as  evidence,  children  of  the  same  family  and  practically  the 
same  exposure  show  much  difference  in  the  conjunctival  tuberculin  reaction; 
those  with  abnormalities  show  reaction,  while  those  free  show  no  reaction. 

The  intimacy  of  the  exposure  counts  a  great  deal.  From  an  analysis  of 
the  report  submitted,  the  occurrence  of  the  conjunctival  reaction  is  more 
frequent  among  those  under  good  housing  conditions,  but  with  abnormal 
head  spaces,  than  among  those  with  poor  housing  and  free  head  spaces.  It 
seems  to  me,  therefore,  that  hygiene  of  the  body,  particularly  the  head  cavi- 
ties, is  a  more  important  prophylaxis.  The  conditions  of  housing  cannot 
always  be  controlled;  the  hygiene  of  the  head  cavities  can  always  be  con- 
trolled. 

Control  of  housing,  feeding,  and  airing  will  not  avail  to  the  greatest  ex- 
tent unless  the  possibility  of  food  and  air  contamination,  when  taken  into 
the  body,  is  removed;  in  other  words,  poorer  food  and  air,  in  a  body  with 
clear  head  cavities,  are  less  baneful  than  good  food  and  air  in  a  body  with 
obstructed  secreting  tissues.  Obstruction  of  the  head  cavities  results  in 
superficial  breathing,  and  tliis  results  in  a  subnormal  standard  of  develop- 
ment and  sub-energized  condition  of  the  bodies. 

The  following  forms  of  history  cards  are  drafted  for  the  purpose  of  study- 
ing the  co-relation  of  predisposing  factors.  The  study  is  practically 
limited  to  the  American  type  of  child.    The  total  number  reported  on  is  1 19. 


SUMMARY. 


Number  Reported  on. 

Age  Last  Birthday,  Yeahs. 

33 

37 

43 

113 

One 

Two 

Three 

i 
i 

2 
4 
4 
3 
2 
4 
2 
4 
2 

i 

1 
1 

i 

2 
1 
2 
1 
6 
2 
2 
3 
1 
1 
2 

1 
4 
4 

1 
1 

2 

1 

1 
1 

2 
4 
3 
4 
4 
3 
2 
3 
7 
1 
2 
2 

3 

i 

3 
3 

4 

Four 

6 

Five 

11 

SLx 

10 

Seven 

10 

Eight 

9 

Nine 

5 

Ten 

8 

Eleven 

11 

Twelve 

6 

Thirteen 

8 

Fourteen 

6 

Fifteen 

2 

Sixteen  

5 

Seventeen 

1 

Eighteen 

0 

Nineteen  

4 

Twenty 

1 

OBSTRUCTIVE   ABNORMALITIES   OF   NOSE   AND   THROAT. — CRONIN. 


517 


NuMBEB  Reported  on. 

Ndmbeb  of  Living-rooms. 

32 

9 

16 

57 

One 

6 

17 

5 

4 

5 
2 

2 

1 

5 

8 
2 

1 

Two 

6 

Three 

27 

Four 

15 

Five 

8 

Six 

0 

Seven 

0 

Number 

Reported  on. 

Number  of  Children  Living. 

32 

13 

15 

60 

One 

4 
3 
10 
4 
6 
5 

3 

5 
5 

1 
3 
6 

5 

5 

Two 

9 

Three 

16 

Four 

9 

Five 

Six 

11 
10 

Seven 

0 

Number  Reported  on. 

Number  of  Children  Dead. 

32 

13 

15 

60 

One 

3 

8 
2 

2 

5 
12 

1 
4 

's 

5 

1 
2 

1 

6 

9 

Two 

12 

Three 

3 

Four 

2 

Five 

2 

Six 

1 

Seven 

5 

Eight 

26 

Number  Families  Reported 

3N. 

NUMBF.R  OF  AdULTB  IN   FaMILY. 

17 

8 

5 

30 

One 

3 
13 

i 

1 
7 

3 

2 

4 

Two 

23 

Three 

2 

Four 

1 

518 


SIXTH   INTERNATIONAL  CONGRESS   ON   TUBERCULOSIS. 


Quality  of  Food. 

Number  Reported  on. 

33 

12 

14 

59 

Good 

15 

18 

5 

7 

7 

7 

27 

Bad 

32 

Service  and  Cooking. 

Number  Reported  on. 

33 

12 

14 

59 

Good 

21 
12 

7 
5 

7 

7 

35 

Bad 

24 

Number  Families  Reported  « 

3N. 

Member  of  Family  Sick. 

16 

21 

20 

57 

Father  and  mother 

3 

10 

2 

1 

1 

i5 

6 

( Adopted 
child) 

ii 

3 

1 

1 

1 
1 

(Two  in 

one 
family) 

3 

Father 

38 

Mother 

11 

Aunt 

1 

Uncle 

1 

Grandfather 

1 

Grandmother 

Brother 

1 

Sister 

1 

Uncle  and  aunt 

1 

Number 

Reported  on. 

Physical  Condition  of  Patient. 

19 

8 

9 

36 

Dead 

1 

3 

15 

3 
3 

2 

1 

3 
5 

5 

In  bed 

9 

At  work 

22 

Expectoration. 

Number  Reported  on. 

15 

6 

6 

27 

Profuse 

10 
5 

4 
2 

3 
3 

17 

Scant 

10 

OBSTRUCTIVE   ABNORMALITIES   OF   NOSE   AND   THROAT, — CRONIN.       519 


Ndmbeb  Reported  on. 

Height. 

Above  standard  (American) 

Normal 

Below  standard 

Number  Reported  on. 

Weight  (American). 

Above  standard 

Normal 

Below  standard 

Nutrition. 

Number  Reported  on. 

33 

12 

11 

56 

Good 

22 
11 

7 
5 

7 
4 

36 

Bad 

20 

Number  Reported  on. 

Glands. 

33 

26 

24 

83 

Enlarged  anterior  cervical  glands 

28 

20 

18 

66 

Posture. 

Number  Reported  on. 

33 

26 

25 

84 

Good 

20 
13 

16 
10 

19 
6 

55 

Bad 

29 

Conformation  of  Chest. 

Number 

Reported  on. 

33 

26 

24 

83 

Good 

Bad 

24 
9 

17 
9 

18 
6 

59 
24 

520 


SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 


Conformation  of  Ribs. 

Number  Reported  on. 

33 

26 

24 

83 

Good 

25 

8 

18 
8 

18 
6 

61 

Bad 

22 

Position  of  Scapula. 

Number 

Reported  on. 

33 

26 

25 

84 

Good 

22 
11 

17 
9 

19 
6 

58 

Bad . .           .            

26 

Teeth  (Decayed,  Premature  Loss, 

Number  Reported  on. 

Deformed  Arches). 

32 

9 

13 

54 

Good 

29 
3 

4 
5 

10 
3 

43 

Bad 

11 

SUMMARY 

SHEI 

:t 

SHOWING 

Phy- 

p 

J)  i 

sical 

Birth 

0 
0 

Food. 

Mem- 

Con- 
di- 
tion. 

Expector- 
ation. 

o 

S 

M 

ber 

Time 

Name. 

"3 

p 

o 
O 

OF 

Fam- 

OF 

Expos- 

^ 

i> 

0) 

0) 

o 

■0 

< 

T5 

'0    . 

ily 

ure. 

't 

o 

^ 

*; 

^ 

fl 

n 

u 

"> 

a 

oj  C 

Sick. 

« 

■5 

Q 

3     P 

-p 

["l 

Q 

'A 

a'" 

a 

s 

00 

2; 

'A 

03 

•a 

eg 

1 

< 

Oh 

Vohlidka,  Emma 

1901 

1889 

1 

3 

B. 
G. 

5 

4 

\ 

\ 

B. 

G. 

B. 
G. 

M. 
F. 

Dead 
2  yrs. 

+ 

+ 
+ 

Walsh,  Anna 

Clancey,  Mary 

1901 

3 

0 

+ 

Dorsey,  Adeline 

Oct. 

4 

B 

6 

1 

3 

B 

B 

GF 

lyr. 

-t- 

-1- 

24, 

and 

1896 

S. 

Preus,  Charles 

Sept. 

2 

2 

0 

2 

G. 

G. 

F. 

+ 

+ 

24, 

1903 

OBSTRUCTIVE   ABNORMALITIES   OF    NOSE   AND   THROAT.— CRONIN.       521 


Oral  Hygiene  (Including  Daily  Toilet  of 

NuMBEB  Reported  on. 

MooTH,  Condition  of  Gums). 

32 

9 

13 

54 

Good 

1 
31 

4 
5 

1 
12 

6 

48 

Bad 

Number  Reported  on. 

Abnormal  Pulmonary  Condition 

33 

23 

35 

91 

Present  in 

3 

1 

10 

14 

Number  Reported  on. 

Tonsils. 

33 

31 

37 

101 

Number  hypertrophied,  including  any 
tonsil    with    enlarged    follicles    pro- 
truding or  submerged 

26 

25 

32 

83 

FIVE 

INDIVIDUAL 

RECORDS. 

Measure- 

Defects of: 

History  of  Child. 

ments. 

i 

i 

o 

s 

a 

ci 
o 

DO 

3 

<u 

i 

"3 
0. 

^ 

V 

6 
a 
<u 
'to 
>. 

n 

"3 

0 

V 

(1 

a 
■3 

d 
_o 

0 
0 

_0 

a  <v 

0  a 

Condition  Si.x 
Months 

ffi 

^ 

O 

2 

3 

o 

s 

^ 

O 

K 

d 
o 
CO 

01 

3 
►-1 

0 

< 

51 
3 

a 

a 

a 
'35 

Subsequent. 

O 

;? 

tf 

0. 
0 

43i 

50 

202 

21 

B. 

+ 

B. 

B. 

B. 

B. 

G. 

G. 

0 

0 

0 

0 

+ 

3:14:08 

3:15:08 

+ 

+ 

B. 

+ 

B 

G. 

G. 

G. 

G. 
B. 

G. 
B. 

0 

+ 

+ 

+ 

+ 
+ 

+ 
+ 

0 
0 

+ 

Ade- 
noids 
and 
ton- 
sils 

No  cough — 
seems  better 
No  coughing 
since  oper- 
ation. 

53 

58 

23 

22 

B. 

+ 

B. 

B. 

B. 

B. 

B. 

B. 

+ 

0 

+ 

+ 

+ 

2:4:08 

2:5:08 

+ 

•• 

34i 

21i 

+ 

B. 

B. 

B. 

B. 

+ 

+ 

+ 

0 

T., 

Ad., 

Uvu- 
la. 

Dec. 
28., 
1907 

522 


SIXTH   INTERNATIONAL   CONGRESS    ON   TUBERCULOSIS. 


Number  Reported  on. 

Adenoids. 

33 

31 

37 

101 

Number  present 

32 

27 

37 

96 

Defective  Nasal  Bbeathino 


Number  obstructed , 


Number  Reported  on. 


33 
33 


29 


25 


35 


35 


97 


93 


Number  Reported  on. 

Number  of  Calmette  Tests  Applied. 

30 

7 

6 

43 

Number  positive 

16 

3 

2 

21 

(Degrees  of  reaction  stated  in  reports  on  each  individual.) 

Number  Reported  on. 

Operations  Performed. 

33 

31 

37 

101 

Includes  tonsillotomy,  adenoidectomy, 
turbincctomy 

5 

5 

3 

13 

A  study  of  this  summary  shows  that*every  individual  is  exposed  to  an 
association  of  predisposing  factors.  A  study  of  the  individual  report  shows 
that  good  home  surroundings  with  a  defective  body  are  Ukely  to  yield  posi- 
tive reaction  to  the  tuberculous  conjunctival  test;  bad  home  surroundings 
with  body  clear,  no  reaction.  The  numbers,  of  course,  are  too  small  to  do 
more  than  indicate  a  profitable  field  of  inquiry. 

The  tonsils  of  some  of  the  cases  reported  on,  were  sent  to  the  Research 
Laboratory.  The  tissues  were  injected  into  guinea-pigs  and  the  following 
report  submitted: 

"New  York,  May  21,  1908. 
"My  dear  Doctor  Cronin: 

"Dr.  Park  asked  me  to  let  you  know  the  results  of  the  injections  of  the 
tissue  you  sent  us,  they  are  as  follows: 

"Thomas  White tuberculosis  positive. 

"Frank  Reehill negative. 

"Theresa  Solomon no  results,  through  loss  of  pig. 

"Leonard  Solomon   ....  pigs  not  yet  autopsied. 


OBSTRUCTIVE   ABNORMALITIES   OF   NOSE   AND   THROAT. — CRONIN.       523 

"The  strain  from  White  appears  very  promising.  If  you  have  any  more 
material  of  the  same  type,  we  should  be  glad  to  have  it. 

"  Yours  truly, 
(Signed)    "Charles  Krumwied,  Jr." 

It  seems  from  the  above  report  that  the  tonsils  and  adenoids  may  be 
primary  foci  of  infection.  Tissues  are  sent  only  from  such  cases  as  show  a 
positive  tuberculin  reaction.  As  a  sort  of  control  on  the  positive  reaction  of 
those  from  tuberculous  homes,  some  300  school  children  who  came  to  the  Good 
Samaritan  Dispensary  for  removal  of  adenoids  and  tonsils  were  systemati- 
cally subjected  to  the  tuberculin  test;  there  was  no  positive  reaction  noted. 
Not  all  the  cases  were  reexamined,  but  personal  experience  shows  that  if 
you  do  anything  to  a  child's  eye,  the  shghtest  disturbance  of  the  eye  will 
result  in  a  revisit.  The  subsequent  eye  test,  after  removal  of  tonsils  from 
those  cases  previously  positive,  was  limited  to  a  few  cases.  One  boy, 
Perlman,  in  six  months  gained  15  pounds  and  had  2-^-  inches  more  expansion; 
a  later  test,  six  months  subsequent  (other  eye  used),  showed  positive  reac- 
tion.    No  physical  signs  were  found. 

I  apologize  for  the  few  cases  reported  on.  The  report  does  not  represent 
the  labor  exerted  to  get  a  greater  number.  All  the  cases  were  visited  at 
their  homes.     I  have  made  as  many  as  eight  visits  to  get  one  case. 

The  addresses  were  obtained  from  Department  of  Health  records,  and 
removals  were  so  frequent  that  few  of  the  cases  looked  up  could  be  found. 

To  conclude:  Obstructions  of  the  head  cavities  prevent  nutritional  and 
developmental  growth;  they  offer  a  favorable  lodgment  for  tubercle  bacilli 
and  may  furnish  a  primary  focus  of  the  disease.  The  growth,  development, 
and  vital  resistance  of  the  child  are  strengthened  after  removal  of  the  ob- 
structions. A  very  high  percentage  of  children  from  tuberculous  homes  are 
constantly  exposed  to  the  disease,  and  the  children  affected  can  scarcely 
expect  to  escape  the  disease.  Laws  should  be  made  to  enable  the  authori- 
ties to  relieve  such  children  of  their  obstructions  and  at  the  same  time 
remove  the  source  of  contagion. 


THE  PLACENTAL  TRANSMISSION  OF  TUBERCULOSIS. 

By  Dr.  Aldred  Scott  Warthin,  Ph.D., 

Professor  of  Pathology  in  the  University  of  Michigan,  Ann  Arbor,  Michigan. 


The  prevailing  opinion  concerning  congenital  tuberculosis,  according  to 
our  text-books,  is  that  it  is  a  pathological  rarity,  constituting  a  practically 
negligible  factor  in  the  etiology  of  tuberculosis.  That  tubercle  bacilli  may 
pass  the  placenta  into  the  fetus,  and  that  tuberculous  lesions  may  occur  in 
the  placenta,  are  now  established  and  accepted  facts,  and  are  recognized  as 
such.  Of  this  form  of  parental  transmission  of  tuberculosis  we  are  sure, 
but  the  practical  world  of  medicine  looks  upon  it  as  an  extremely  rare 
occurrence.  The  old  positive  teachings  concerning  the  inheritance  of 
tuberculosis  have  almost  wholly  given  place  to  negative  dicta  concerning 
this  point.  As  a  result  of  the  current  teachings  regarding  "non-inheritance" 
of  tuberculosis  there  can  be  but  little  doubt  that  of  recent  years  there  has 
been  an  increasing  laxity  concerning  marriage  and  pregnancy  in  the  case  of 
tuberculous  women.  Even  when  the  personal  risk  has  been  pointed  out, 
the  desire  for  maternity  has  led  many  tuberculous  women  to  undergo 
pregnancy  in  the  belief  that  the  progeny  would  not  necessarily  be  tuber- 
culous. 

It  becomes  a  question  of  importance,  therefore,  if  we  have  not  gone  too 
far  in  our  statements  and  have  given  a  wrong  impression.  That  there  can 
be  no  "true  heredity"  of  tuberculosis  we,  of  course,  recognize,  since  tuber- 
culosis is  due  to  an  extrinsic  agent.  But  the  statement  "no  heredity  in 
tuberculosis"  cannot  be  taken  to  mean  "no  maternal  transmission."  This 
latter  thing  is  a  definitely  proved  occurrence.  Not  only  this,  but  it  is  highly 
probable  that  a  tuberculous  woman  becoming  pregnant  will  transmit  the 
bacillus  to  her  child  in  utero.     Everything  favors  such  a  possibility. 

The  actual  number  of  observed  cases  of  placental  tuberculosis  is  but 
thirty,  and  the  cases  of  congenital  tuberculosis  in  which  the  intrauterine 
transmission  is  beyond  any  doubt  are  even  fewer.  The  small  number  of 
these  observed  cases  cannot,  however,  be  taken  as  an  absolute  criterion  of 
the  frequency  of  occurrence.  It  is  highly  significant  that  the  cases  of  pla- 
cental tuberculosis  have  been  seen  by  relatively  a  small  number  of  observers, 

624 


THE   PLACENTAL   TRANSMISSION   OF   TUBERCULOSIS. — WARTHIN.         525 

Schmorl  and  Geipel  alone  having  seen  nearly  a  third  of  the  cases.  The 
conditions  do  not  favor  the  easy  recognition  of  placental  infections.  Rela- 
tively few  placentas  are  systematically  examined,  and  the  immense  amount 
of  time  and  labor  necessary  for  the  thorough  examination  of  one  before 
a  negative  result  can  be  given  limits  decidedly  the  number  of  such  examin- 
ations. 

The  wTiter  believes  that  if  thorough  and  systematic  examinations  of  the 
placentas  of  all  tuberculous  mothers  could  be  carried  out,  there  would  be  a 
surprisingly  large  number  of  cases  of  placental  tuberculosis  reported — simply 
because  the  conditions  favor  its  occurrence.  We  know  that  tubercle  bacilli 
enter  the  blood  of  tuberculous  individuals,  and  that  they  pass  into  the  semen, 
urine,  and  other  discharges  even  when  there  is  no  local  lesion.  Even  when 
the  primary  focus  is  small,  at  certain  stages  tubercle  bacilli  pass  into  the 
blood-stream.  This  event  is  particularly  likely  to  happen  in  the  case  of  a 
tuberculous  mother  becoming  pregnant.  Under  the  changed  metabolism 
of  the  pregnant  condition  small  and  non-active  tuberculous  foci  are  particu- 
larly likely  to  become  more  active  and  the  process  to  spread.  This  is  a 
common  clinical  observation.  Many  writers  emphasize  the  harmful  influence 
of  pregnancy  in  its  influence  in  kindling  anew  a  quiescent  process.  It  is 
during  such  exacerbations  of  activity  that  the  tubercle  bacilli  are  particularly 
likely  to  enter  the  blood-stream. 

Once  in  the  blood-stream  of  the  pregnant  woman  the  bacilli  are  particu- 
larly likely  to  drop  out  of  the  circulation  in  the  slowly  moving  blood-stream 
of  the  large  placental  sinuses.  Coming  into  contact  with  the  endothelium 
of  the  decidual  sinuses  local  necrosis  or  degeneration  of  the  latter  may  ensue. 
This  is  followed  by  a  thrombosis,  and  the  formation  of  a  tuberculous  decidual 
lesion  is  initiated.  In  the  intervillous  sinuses  the  same  thing  may  occur. 
The  bacilli  lodging  upon  the  syncytial  layer  of  the  chorionic  villi  produce  in 
this  layer  degeneration  and  necrosis,  leading  to  thrombus-formation  in  the 
maternal  blood-spaces.  We  know  now  that  the  chorionic  sync}i;ium  pos- 
sesses no  especial  resistance  to  the  tubercle  bacillus  or  to  the  majority  of  the 
infections.  It  is  no  more  immune  to  the  action  of  the  tubercle  bacillus  than 
is  the  vascular  endothelium  in  any  part  of  the  body.  On  the  contrary,  it 
would  appear  from  the  cases  so  far  observed  that  the  chorionic  ectodermal 
covering  is  easily  injured  by  the  bacilli  gaining  entrance  to  the  placental 
sinuses.  Further,  we  know  now  that  the  placenta  is  no  sure  filter  of  the 
microorganisms  or  their  proteins  circulating  in  the  maternal  blood.  Patho- 
genic bacteria  may  pass  the  syncytium  without  producing  in  it  any  apparent 
lesion,  and  the  chorionic  covering  is  unable  to  hold  back  any  proteins  circu- 
lating in  the  maternal  blood.  This  is  true  of  the  tubercle  bacillus,  its  aggres- 
sins,  and  its  poisons.  It  must  not  be  forgotten  that  the  chorion  is  in  a  state 
of  constant  retrogression  and  proliferation.    Even  from  the  earliest  stages  of 


526  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

pregnancy,  degeneration  and  necrosis  of  some  of  the  villi  and  thrombosis 
of  the  intervillous  spaces  occur.  Infarcts  may  be  formed  at  any  period, 
but  are  more  common  after  the  first  half  of  pregnancy.  Such  physiological 
lesions  offer  weak  spots  in  the  protective  capacity  of  the  placenta,  and 
through  such  syncytium  of  lowered  vitality  microorganisms  may  pass  and 
retain  their  virulence. 

The  placental  transmission  of  tuberculosis  depends  upon  the  passage  of 
tubercle  bacilli  through  the  placenta.  Associated  with  this  passage  of  the 
infective  agent  are  the  complex  factors  of  the  transmission  of  toxin,  anti- 
toxin, aggressin,  antiaggressin,  bacterial  protein,  etc.  One  or  all  of  these  fac- 
tors may  play  a  part  in  the  problem.  We  are  concerned  here,  however,  with 
the  transmission  of  the  infective  agent — the  tubercle  bacillus.  Its  passage 
may  be  direct  from  the  maternal  blood  to  fetal  without  placental  lesions,  or 
the  latter  may  be  formed  and  from  these  the  bacilli  may  pass  into  the  fetal 
circulation.     In  any  given  case  both  events  may  take  place. 

In  the  case  of  the  bacillus  passing  the  syncytium  without  apparent 
damage  to  the  latter,  we  are  unaware  of  the  exact  mechanism  by  which 
this  occurs.  It  is  probable  that  the  process  is  wholly  like  that  occurring  in 
the  passage  of  tubercle  bacilli  through  an  uninjured  intestinal  mucosa.  The 
bacilli  may  be  taken  up  by  leukocytes  or  the  syncytium  itself  may  perform 
phagocytosis.  It  must  not  be  forgotten  also  that  some  writers  ascribe  to 
the  tubercle  bacillus  an  active  role  in  passing  through  the  intestinal  wall, 
and  this,  if  true,  would  apply  also  to  its  passage  through  the  placenta. 
At  any  rate  tubercle  bacilli  may  be  demonstrated  in  the  syncytium,  in  the 
interior  of  villi,  and  in  the  chorionic  vessels  in  the  entire  absence  of  any 
lesions  of  the  same. 

With  the  pathology  of  placental  tuberculosis  we  are  now  in  a  position 
to  become  fully  familiar.  The  studies  of  Schmorl  and  Geipel  and  those  of 
the  writer  have  given  us  a  fairly  complete  pathology  of  placental  tuberculosis, 
and  we  know  that  it  manifests  itself  in  five  forms:  (1)  Decidual,  (2)  inter- 
villous, (3)  intravillous,  (4)  intravascular  chorionic,  (5)  chorioaraniotic. 
Of  these,  the  most  common  forms  are  the  decidual  and  intervillous 
lesions. 

1.  Tuberculosis  of  the  decidua  is  characterized  by  an  absence  of  tubercle- 
formation.  As  a  result  of  the  lodgment  of  tubercle  bacilli  upon  the  endo- 
thelium of  the  decidual  sinuses  there  is  a  local  necrosis  of  the  endothelium, 
followed  by  the  formation  of  an  agglutination-thrombus  in  the  sinus.  Fol- 
loTving  this  there  is  a  secondary  caseation.  Giant-cells  and  epithelioid 
cells  are  apparently  not  formed  by  the  decidua  or  endothelium  of  the  decidua. 
Tubercle  bacilli  passing  out  of  the  blood-stream  into  the  decidua  cause  a  focal 
degeneration  and  necrosis  of  the  decidual  cells.  Such  areas  are  easily 
distinguished  in  the  stained  sections  by  their  darker  staining,  greater  density, 


THE    PLACENTAL   TRANSMISSION   OF   TUBERCULOSIS. — WARTHIN.         527 

and  abundance  of  fibrin.  They  are  always  surrounded  by  a  zone  of  necro- 
biosis containing  numerous  disintegrating  leukocytes.  The  nuclear  karyor- 
rhexis  is  a  distinguishing  feature  of  these  foci.  In  the  later  stages  of  the 
process  the  centers  of  the  foci  may  show  complete  caseation  and  a  partial 
liquefaction.  Such  older  tuberculous  foci  might  easily  be  mistaken  for 
small  abscesses,  but  the  absence  of  polynuclear  leukocytes  in  numbers  and 
the  character  of  the  changes  in  the  tissue  immediately  surrounding  such  foci 
make  the  differential  diagnosis  not  cUfficult. 

In  this  place  I  wish  to  record  a  new  case  of  decidual  tuberculosis: 

Patient,  woman  aged  thirty-seven,  mother  of  seven  healthy  children  and 
in  second  month  of  eighth  pregnancy,  began  to  show  marked  emaciation, 
fever,  and  general  weakness.  Diagnosed  as  "cancer  of  the  stomach"  and 
sent  to  the  University  Hospital  for  operation.  On  arrival  her  condition 
was  so  serious  that  a  complete  examination  was  not  possible,  but  the  diag- 
nosis of  cancer  of  the  stomach  was  rejected,  and  that  of  tyjDhoid  fever  or 
acute  tuberculosis  considered.  Patient  died  a  few  days  after  entrance. 
The  autopsy  showed  an  advanced  tuberculosis  of  the  oviducts  and  uterus 
and  an  acute  general  miliary  tuberculosis.  The  uterus  was  as  large  as  the 
uterus  of  four  months'  pregnancy.  On  opening  it  no  trace  of  fetus  could 
be  found.  The  decidua  was  hyperplastic  and  contained  numerous  large,  soft, 
caseous  areas.  Similar  caseous  areas  were  found  throughout  the  uterine 
wall.  The  microscopical  examination  showed  an  advanced  tuberculous 
caseation  of  decidua  and  large  caseating  tubercles  throughout  the  uterine 
wall.  No  history  of  any  symptoms  of  abortion  could  be  obtained,  but  no 
trace  of  fetus  or  chorion  could  be  found. 

The  absence  of  tubercle-formation  in  the  decidua  of  this  case  is  in  accord 
with  the  previous  observations  concerning  decidual  tuberculosis.  In  the 
cases  reported  by  Runge,  Westenhoeffer,  Schmorl  and  Geipel,  and  WoUstein, 
and  in  my  previously  reported  cases,  the  decidual  lesions  of  tuberculosis 
have  all  been  of  the  nature  of  a  caseation  necrosis  associated  with  thrombosis 
and  without  epithelioid  and  giant-cell  formation.  Only  in  the  deepest 
layer  of  the  decidua  or  in  the  immediate  neighborhood  of  a  chorionic  villus 
are  epithelioid  and  giant-cells  found  invading  decidual  caseous  foci.  The 
peculiar  character  of  the  decidual  cells  must  be  regarded  as  sufficient  reason 
for  their  failure  to  form  reactive  tubercles. 

2.  The  intervillous  tubercles  are  the  result  of  tubercle  bacilli  lodging  upon 
the  syncytium  and  causing  in  the  latter  a  local  degeneration  and  necrosis. 
Following  this  there  is  formed  upon  the  damaged  syncytium  an  agglutina^- 
tion-thrombus  of  red  cells  and  leukocytes,  the  latter  of  which  quickly  show 
karyorrhexis.  Fibrin-formation  occurs,  and  there  is  found  in  the  inter- 
villous space,  but  attached  to  the  syncytium  at  point  of  damage,  a  deeply 
staining,  dense,  granular  mass  staining  a  violet-red  (hematoxylin  and  eosin) 
and  containing  numerous  chromatin  granules  and  karyorrhexic  leukocyte 


528  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

nuclei.  From  the  stroma  of  the  villus  epithelioid  and  giant-cells  may  now 
enter  the  agglutination-thrombus,  and  it  may  become  wholly  or  partly 
organized  into  an  intervillous  tubercle.  Secondary  caseation  of  the  tubercle 
thus  formed  may  now  take  place.  In  other  instances  caseation  of  the  agglu- 
tination-thrombus proceeds  without  the  formation  of  a  tubercle.  The  differ- 
ence in  process  is  probably  due  to  variation  in  the  \drulence  of  the  given 
infection. 

3.  Intravillous  tubercles  are  formed  in  the  stroma  of  the  villi  by  tubercle 
bacilli  passing  the  s}'ncytial  layer  and  lodging  in  the  tissue-spaces  of  the 
stroma  of  the  villus.  At  the  point  of  growth  of  the  bacillus  there  is  formed 
a  primary  degeneration  or  necrosis;  this  is  followed  by  the  development 
of  a  tubercle  presenting  the  general  appearances  of  tubercles  elsewhere  in 
the  body  and  showing  the  same  course. 

4.  Intrachorionic  vascular  tubercles  are  formed  in  the  chorionic  vessels 
by  tubercle  bacilli  gaining  entrance  to  the  fetal  circulation  and  lodging 
upon  the  endothelium  of  the  vessels  of  the  chorion.  Here  the  process  is 
repeated:  first,  a  primary  degeneration  or  necrosis  of  the  endothelium  at 
point  of  lodgment  of  the  bacilli,  then  the  formation  of  an  agglutination- 
thrombus,  its  secondary  caseation,  or  its  organization  into  an  epithelioid 
tubercle  with  subsequent  caseation.  The  process  is  essentially  the  same  as 
that  of  intravascular  tubercle-formation  in  any  part  of  the  body. 

5.  Chorio amniotic  tubercles  are  rare.  They  usually  arise  primarily 
in  the  chorionic  villi  adjoining  the  amnion,  and  involve  the  latter  by  direct 
continuity  or  contiguity.  Their  manner  of  formation  is  identical  Tsith  that 
of  the  chorionic  tubercles  and  the  after-changes  are  the  same.  Primary 
tuberculous  foci  of  degeneration  may  also  be  found  in  the  amnion;  the 
development  of  these  into  tubercles  has  not  yet  been  observed  in  any  of  its 
stages.  Even  in  the  most  extensive  miliary  tuberculosis  of  the  placenta 
the  amnion  may  fail  to  show  any  tuberculous  lesions,  although  the  amniotic 
fluid  may  contain  tubercle  bacilli  in  large  numbers. 

In  brief  these  are  the  most  essential  features  of  the  pathology  of  placental 
tuberculosis.  As  I  have  said  before,  of  this  form  of  maternal  transmission 
of  tuberculosis  to  the  progeny  we  have  now  abundant  and  conclusive  proof. 
The  main  question  now  before  us  is  the  frequency  of  such  an  event.  It 
will  be  manifestly  impossible  to  secure  accurate  statistics  in  regard  to  a  point 
the  inve.stigation  of  which  is  attended  by  so  many  difficulties.  But  there 
are  very  good  reasons  for  believing  that  pregnancy  in  a  tuberculous  woman 
is  attended  not  only  by  danger  to  herself,  but  by  the  very  grave  danger  of  the 
placental  transmission  of  the  disease  to  the  offspring.  The  most  important 
of  these  reasons  are  as  follows: 

1.  Tuberculous  individuals,  even  in  the  presence  of  a  small  active  focus, 
give  off  active  bacilli  into  the  blood-stream. 


THE    PL-\CEXTAL   TRANSMISSION    OF    TUBEKCULOSIS. — W.^JITHIN.  529 

2.  Under  the  influence  of  pregnancy  there  is  especial  danger  of  an  old 
quiescent  tuberculous  focus  again  becoming  active  and  gi'v'ing  off  bacilli 
into  the  blood-stream. 

3.  Tubercle  bacilh  circulating  in  the  blood  of  the  mother  are  particularly 
likely  to  fall  out  of  the  circulation  in  the  large  placental  sinuses. 

4.  The  decidua  and  the  chorionic  sjTicj'tium  offer  no  especial  resistance 
to  the  tubercle  bacillus.  They  have  no  special  immunity,  and  are  affected 
by  the  agents  of  infection  in  the  same  way  as  is  the  vascular  endotheUum  in 
any  other  part  of  the  body. 

5.  Active  tubercle  bacilli  may  pass  through  the  placenta  into  the  fetal 
circulation  without  causing  any  placental  lesions. 

6.  From  placental  lesions  large  numbers  of  tubercle  bacilli  may  enter  the 
fetal  circulation. 

The  passage  of  tubercle  bacilli  through  the  placenta  without  producing 
pathological  changes  in  that  organ  has  an  important  bearing  upon  the 
subject  of  latent  congenital  tuberculosis.  Further,  it  has  been  positively 
sho^Ti  that  the  fetal  blood  may  contain  tubercle  bacilU  in  large  numbers 
without  tuberculous  lesions  being  produced  in  the  fetal  tissues.  Such  an 
occurrence  can  easily  be  explained  on  the  ground  of  an  acquired  aggressin- 
immunity  on  the  part  of  the  fetus.  The  passage  through  the  placenta  of 
tubercle  aggressin  in  small  amount,  for  a  long  period  of  time,  would  produce 
in  the  fetus  an  aggressin-immunity,  and  so  permit  the  presence  in  the  fetal 
blood  of  tubercle  bacilli  without  the  production  of  lesions,  or  the  latter, 
if  produced,  might  be  very  slight  and  of  slow  development.  A  toxin-iromun- 
ity  may  also  be  produced.  Latency  in  the  fetus  or  child,  of  bacilli  obtained 
from  the  mother,  is  both  possible  and  probable. 

In  conclusion,  we  must  substitute  for  our  dictum  "  no  inheritance  in  tuber- 
culosis," the  warning  "maternal  transmission  of  tuberculosis  is  Ukely  to 
occur,"  and  we  should  modify  our  extreme  statements  concerning  the 
frequency  of  congenital  tuberculosis.  If  tuberculosis  is  to  be  exterminated, 
all  modes  of  infection  and  spread  must  be  guarded  against,  hence  marriage 
and  maternity  in  the  case  of  tuberculous  individuals  should  be  prohibited 
or  avoided. 


La  Trasmicion  de  la  Tuberciilosis  por  Medio  de  la  Placenta. — (Warthin.) 

Esta  condicion  generalmente  considerada  de  una  raresa  extrema.  Anali- 
sis  de  los  casos  reportados.  Nuevos  casos  del  autor.  Las  doctrinas  del 
presente,  que  niegan  la  transmicion  hereditaria  de  la  tuberculosis,  es  respon- 
sable  de  la  poca  atencoin  que  se  da  a  los  asuntos  de  matrimonio  y  embarazo 
en  los  casos  de  las  mujeres  tuberculosas.     Tuberculosis  congenital  como  un 


530  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

resultado  de  transmicion  por  medio  de  la  placenta.  En  la  mujer  tuber- 
culosa, durante  el  embarazo,  auii  en  los  primeros  estados  de  la  infeccion, 
las  condiciones  son  favorables  a  la  entrada  del  bacilo  de  la  tuberculosis  en 
el  torrente  circulatorio  y  de  este  a  los  tejidos  de  la  placenta.  Una  vez  el 
bacilo  en  el  seno  de  la  placenta,  este  puede  ser  Uevado  por  la  circulacion 
bien  a  la  decidua,  al  endotelio  o  bien  al  corio. 

El  corio  no  presenta  resistencias  especiales  al  bacilo  de  la  tuberculosis, 
sino  que  a  lo  contrario  es  denado  facilmente  por  el  bacilo,  el  cual  pasa,  a 
los  vasos  sanguineos  de  la  placenta.  Estos  no  son  mas  inmunes  d  la  accion 
del  bacilo  de  la  tuberculosis  que  lo  es  el  endotelio  vascular  de  cualquier 
otra  parte  del  organismo.  La  acumulacion  del  bacilo  acitvo,  da  origen  a 
una  degeneracion  y  necrosis  en  el  sitio  de  la  infeccion,  esta  A  la  vez  da  lugar 
d  la  aglutinacion  de  un  coagulo,  el  cual  mas  tarde  llega  a  organizarse  en  la 
forma  de  un  tuberculo  con  sus  celulas  epiteleales  y  gigantes,  traidas  por 
medio  de  la  circulaci6n.  Una  degeneracion  secundaria  caseosa  puede  tam- 
bien  ocurrir.  El  bacilo  de  la  tuberculosis  puede  tambien  pasar  al  traves 
de  los  tejidos  sin  presentar  danos  aparentes. 

La  tuberculosis  en  la  placenta  se  manifiesta  bajo  cinco  formas: — (1) 
Decidual;  (2)  Intervellosa;  (3)  Intravellosa;  (4)  Intravascular  en  el  corio; 
(5)  Corio-amniotica.  Las  mas  comunes  son  las  lesiones  deciduales  e  inter- 
vellosas.  En  el  caso  en  que  la  decidua  es  afectada,  la  formacion  de  tuber- 
culos  es  absente,  las  lesiones  de  la  decidua,  consisten  de  una  area  de  necrosis 
y  coagulo  localizado  sin  la  formacion  de  celulas  epiteloales  ni  gigantes.  El 
primer  evento  en  estas  lesiones  es  la  necrosis  del  endotelio  de  los  senos  de  la 
decidua,  en  los  puntos  donde  se  encuentra  alojado  el  bacilo  de  la  tubercu- 
losis. En  las  lesiones  intervellosas  la  necrosis  es  el  primer  evento.  Las 
lesiones  del  endotelio  ocasionan  la  formacion  de  un  coagulo  hialino  que,  mas 
tarde  puede  transformarse  en  un  tuberculo  epitelial.  El  mismo  fenomeno 
presentan  las  lesiones  de  los  vasos  del  corion. 

Aunque  el  bacilo  de  la  tuberculosis  puede  pasr  al  traves  de  la  placenta 
sin  producir  lesiones  aparentes,  la  ausencia  de  estas,  sinembargo,  no  justi- 
fica  que  el  feto  haya  escapado  la  infeccion.  En  los  casos  de  infecciones 
de  la  placenta,  las  probalidades  son  que  el  bacilo  de  la  tuberculosis  haya 
entrado  en  la  circulacion  del  feto.  En  el  torrente  circulatorio  del  feto  el 
bacilo  puede  encontrarse  en  gran  numero,  sin  que  por  esto  cause  lesiones 
locales. 

En  conclusion,  la  ocurrencia  del  embarazo  en  la  mujer  tuberculosa, 
favorece  la  entrada  del  bacilo  de  la  tuberculosis  en  el  torrente  circulatorio 
y  en  los  senos  de  la  placenta.  La  placento  no  es  un  filtro  perfecto  para  los 
microbios  ni  tampoco  pose6  una  immunidad  especial  contra  el  bacilo  de  la 
tuberculosis.  La  transmicion  de  la  tuberculosis  por  medio  de  la  placenta, 
es  un  factor  definitivo  y  no  una  rara  posibilidad  en  la  etiologia  de  la  tuber- 


THE   PLACENTAL   TRANSMISSION   OF   TUBERCULOSIS. — WARTHIN.         531 

culosis  congenital  la  cual,  auque  relativamente  rara,  es  mas  frecuente  que 
como  se  cree,  y  debe  considerarse  como  una  posibilidad  definidad  en  todo 
caso  en  el  cual  la  cuestion  de  matrimonio  y  embarazo  de  la  mujer  tuberculosa 
se  tome  en  consideracion. 


Transmission  de  la  Tuberculose  par  le  Placenta. — (Warthin.) 

Etat  present  de  la  question  de  la  tuberculose  cong^nitale.  Cette  forme 
est  consideree  d'habitude  comme  extremement  rare.  Analyse  des  cas  rap- 
port^s  jusq'ua  present.  Cas  nouveaux  vus  par  I'auteur.  L'enseigne- 
ment  concernant  la  non-her6dite  "de  la  tuberculose,  est  responsable  de 
indulgence  trop  grande  dans  les  manages  des  tubercluleux  et  dans  la 
grossesse  des  femmes  tuberculeuses.  La  tuberculose  congenitale  est  le 
resultat  de  la  transmission  du  bacille  par  le  placenta.  Chez  la  femme 
tuberculeuse  enceinte,  meme  dans  la  premiere  phase  de  I'infection,  il  y  a 
des  circonstances  qui  favorisent  I'entree  des  bacilles  dans  le  courant  de 
la  circulation  et  de  la  dans  les  sinus  placentaires.  L^,  les  bacilles  peuvent 
sortir  de  la  circulation,  soit  en  passant  dans  I'endothelium  de  la  membrane 
decidue  soit  dans  le  syncytium  du  chorion. 

Le  syncytium  du  chorion  n'a  pas  de  resistance  speciale  a  opposer  au 
bacille  de  la  tuberculose.  Au  contraire,  il  semble  etre  facilement  blesse 
par  les  bacilles,  qui  entrent  ainsi  dans  les  sinus  placentaires.  Le  syncytium 
n'est  pas  plus  immun  k  Taction  du  bacille  que  ne  Test  I'endothelium  vas- 
culaire  de  n'importe  quelle  partie  du  corps.  La  colonisation  de  bacilles 
actifs  sur  le  syncytium  est  suivie  de  degeneresence  et  de  necrose  du  syncy- 
tium, au  point  ou  les  bacilles  s'etablissent.  Apres,  formation  d'une  throm- 
bose d'agglutination  sur  le  syncytium  endommage.  Cette  thrombos 
s'organise  plus  tard  et  devient  un  tubercule,  les  cellules  4pitheloides  et  les  cel- 
lules geantes  provenant  du  tissu  de  la  villosit6.  Degen^rescence  cas^euse 
peut  avoir  lieu  ensuite.  D'un  autre  c6t6,  les  bacilles  peuvent  passer  le  syn- 
cytium sans  I'endommager,  selon  toute  apparence. 

La  tuberculose  du  placenta  se  manifeste  par  cinq  formes:  (1)  Tubercu- 
lose de  la  membrane  decidue;  (2)  intei-villeuse;  (3)  intravilleuse;  (4)  intra- 
vasculaire  chorionique;  (5)  chorio-amniotique.  Les  formes  les  plus  communes 
sont  les  lesions  de  la  membrane  decidue  et  les  lesions  intervilleuses.  Dans 
le  cas  des  lesions  deciduelles,  des  tubercules  ne  se  forment  jamais,  la  lesion 
consistant  en  une  region  ou  la  necrose  et  la  thrombose  se  localisent  sans 
qu'il  y  ait  formation  de  cellules  ^pith^loides  et  de  cellules  geantes.  Le 
premier  ph6nom6ne  de  cette  16sion  est  la  necrose  de  I'endothelium  du  sinus 
ddciduel,  qui  a  lieu  au  point  ou  le  bacille  s'est  etal)li.  Dans  les  16sions  in- 
tervilleuses, la  necrose  syncytielle  a  lieu  d'  abord.  Les  lesions  de  I'endo- 
th^lium  ou  du  syncytium  conduisent  k  la  formation  de  thromboses  hyalines 


532  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

ou  par  agglutination,  lesquelles,  plus  tard,  peuvent  se  transformer  en  tul^er- 
cules  ^pith^loides.  Le  meme  proces  a  lieu  dans  les  lesions  provenant  des 
vaisseaux  du  chorion. 

Puisque  les  bacilles  peuvent  passer  le  placenta  sans  causer  des  lesions 
locales,  I'absence  de  ces  dernieres  ne  signifie  pas  que  la  foetus  a  6t6  sauv6 
de  I'infection.  Naturellement  ou  il  y  la  des  lesions  placentaires,  il  est  beau- 
coup  plus  probable  que  des  bacilles  soient  entr^s  dans  la  circulation  foetale. 
Les  bacilles  peuvent  se  trouver  en  grand  nombre  dans  le  courant  foetal,  sans 
provoquer  des  lesions  locales.  II  est  tres  probable  que  des  infections  "la- 
tentes"  du  nouveau-n6  peuvent  avoir  lieu. 

Conclusion:  La  grossesse  d'une  femme  tuberculeuse  favorise  I'entr^e  des 
bacilles  de  la  tuberculose  dans  la  circulation,  et  puis  dans  les  sinus  placen- 
taires. Le  placenta  n'est  pas  un  filtre  parfait  pour  les  microorganismes. 
Elle  n'a  pas  d'immunite  sp^ciale  contre  le  bacille  de  la  tuberculose.  La 
tuberculose  cong^nitale  comme  r^sultat  de  la  transmission  placentaire  est 
un  facteur  defini  dans  I'^tiologie  de  la  tuberculose  est  on  ne  pent  pas  I'ignorer 
en  disant  simplement  que  c'est  une  rare  possibilite.  Quoiqu'elle  soit  rare 
relativement,  elle  est  plus  commune  qu'on  ne  le  suppose  et  on  ne  doit  pas 
I'oublier  la  oil  il  faut  considerer  les  questions  du  mariage  et  de  la  grossesse 
de  ferames  tuberculeuses. 


Die  Placentar-Ubertragung  der  Tuberkulose. — (Warthin.) 
Gegenwartiger  Stand  der  congenitalen  Tuberkulose.  Diese  Kondition 
fiir  gewohnlich  als  ausserordentlich  selten  angesehen.  Analyse  der  berichte- 
ten  Falle.  Neue  Falle  vom  Autor.  Mitlaufende  Lehren  beziiglich  der 
"  Nicht-Erblichkeit "  der  Tuberkulose  verantwortlich  fiir  anwachsende 
Laxheit  beziiglich  Heiraten  und  Schwangerschaften  in  den  Fallen  tuberku- 
loser  Frauen.  Congenitale  Tuberkulose  das  Resultat  einer  placentaren 
Ubertragung.  Bei  der  schwangeren  tuberkulosen  Frau,  selbst  in  dem 
friihen  Stadium  der  Infektion,  begiinstigen  Zufalle  den  Eintritt  von  Bazillen 
in  den  Blutstrom  und  von  da  in  die  Sinusse  der  Placenta.  Hier  konnen  die 
Bazillen  aus  der  Zirkulation  sich  entweder  in  das  Endothel  der  Decidua 
oder  in  das  Zellengewebe  des  Chorions  begeben. 

Das  Zellengewebe  des  Chorions  besitzt  dem  Tuberkelbazillus  gegen- 
iiber  keine  besondere  Widerstandskraft.  Es  scheint  im  Gegenteile  leicht 
durch  die  Bazillen  verletzt  zu  werden,  welche  Eintritt  in  die  Sinusse  der 
Placenta  gewinnen.  Es  ist  gegeniiber  der  Tatigkeit  des  Tuberkelbazillus 
nicht  mehr  immun,  als  das  gefassreiche  Endothel  in  irgend  einera  Telle  des 
Korpers.  Das  Lasten  der  Bazillen  auf  dem  Syncytium  zieht  eine  Degenera- 
tion und  Nekrose  des  Syncytiums  auf  dem  Belastungspunkte  nach  sich. 


THE   PLACENTAL  TRANSMISSION   OF   TUBERCULOSIS. — WARTHIN.         533 

Dieser  Thrombus  organisiert  sich  spater  in  einen  Tuberkel,  da  die  Epithel- 
und  Riesenzellen  von  dem  Stroma  des  Villus  kommen. 

Es  mag  auch  zu  secundarer  Verkasung  kommen.  Tuberkelbazillen 
konnen  auch  anscheinend,  ohne  eine  schadliche  Wirkung  zu  zeigen,  durch 
ein  Syncytium  passieren. 

Die  Tuberkulose  der  Placenta  tritt  in  5  Formen  auf : 

(1)  Decidual;  (2)  Intervillos;  (3)  Intravillos;  (4)  Intravascular  chorio- 
nisch;  (5)  Chorio-amniotisch.  Die  gewohnUchsten  Formen  sind  die  decidua- 
len  und  intervillosen  Verletzungen.  In  den  Fallen  der  ersteren  bilden  sich 
niemals  Tuberkel,  da  die  decidualen  Verletzungen  aus  einer  ortlich  begrenz- 
ten  Flache  von  Nekrose  und  Thrombose  ohne  die  Bildung  von  Epithel- 
oder  Riesenzellen  bestehen.  Der  primare  Effekt  in  dieser  Verletzung  ist 
die  Nekrose  des  Endothels  der  decidualen  Sinusse  an  jenem  Punkt,  an  dem 
sich  der  Tuberkelbazillus  eingestellt  hat.  In  den  intervillosen  Verletzun- 
gen ist  Nekrose  des  Syncytiums  der  primare  Effekt.  Die  Verletzungen  des 
Endothels  oder  Syncytiums  fiihren  zu  der  Bildung  hyaliner  oder  agglutinir- 
ter  Thromben,  welche  spater  in  Epithel-Tuberkel  verwandelt  werden  konnen. 
Derselbe  Prozess  kommt  in  den  Verletzungen  vor,  die  sich  in  den  Gefassen 
des  Chorions  ergeben. 

Seitdem  Tuberkelbazillen  die  Placenta  passieren,  ohne  lokale  Verletz- 
ungen zu  verursachen,  giebt  die  Abwesenheit  der  letzteren  noch  kein  Zeichen, 
dass  der  Fotus  der  Infektion  entwischt  ist.  In  den  Fallen  placentarer  Ver- 
letzungen sind  die  Moglichkeiten  unendlich  grosser,  dass  Bazillen  Einlass 
in  die  fotale  Zirkulation  erlangen.  Im  fotalen  Blutstrom  konnen  sie  in 
grosser  Anzahl,  ohne  lokale  Verletzungen  zu  verursachen,  vorhanden  sein. 
Das  Vorkommen  "latenter"  Infektionen  der  Neugeborenen  ist  sehr  leicht 
moglich. 

Zur  Schlussfolgerung:  das  Vorkommen  der  Schwangerschaft  einer 
tuberkulosen  Frau  begiinstigt  den  Eintritt  von  Tuberkelbazillen  in  den 
Blutstrom  und  von  da  in  die  Sinusse  der  Placenta.  Die  Placenta  ist  kein 
geniigender  Filter  fiir  Mikro-Organismen.  Sie  besitzt  keine  besondere 
Immunitat  gegen  den  Tuberkelbazillus.  Angeborene  Tuberkulose  als  das 
Resultat  placentarer  Ubertragung  ist  ein  bestimmter  Faktor  in  der  Atio- 
logie  der  Tuberkulose,  und  kann  mit  ihrer  entschiedenen  Erkennung  nicht 
als  eine  sehr  seltene  Moglichkeit  bei  Seite  geschoben  werden.  Wahrend 
sie  relativ  selten  ist,  ist  sie  dennoch  hilufiger  als  man  vermutet,  und  muss 
als  eine  bestimmte  Moglichkeit  in  alien  Fallen  betrachtet  werden,  in  welchen 
die  Fragen  der  Heirat  oder  Schwangerschaft  tuberkuloser  Frauen  in  Er- 
wagung  kommen. 


DE  L'AIR  CONFINE  ET  DE  LA  TUBERCULOSE. 

Par  M.  L'Architecte  Augustin  Rey, 

Membre  du  Conseil  Superieur  dea  Habitations  h  Paris. 


Probleme  DE  L' Aeration  de  la  Chambre  Habitee. 

Lorsqu'il  s'agit  de  tuberculose,  i'^tude  de  Tatmosphere  confin^e,  en 
opposition  avec  I'atmosphere  libre,  devient  de  la  plus  haute  importance. 

La  respiration,  fonction  fondamentale  de  la  vie,  quand  elle  s'accomplit 
a  I'air  exterieur  a  presque  toujours  une  resultante  niecanique  et  physique 
absolument  normale. 

Dans  Fair  confine,  il  en  est  au  contraire  tout  autrement. 

Le  mouvement  a^rien  dans  un  espace  clos,  est  si  complexe,  en  apparence, 
qu'il  permet  difficilement  de  determiner  d'une  maniere  precise,  les  ph^nom- 
enes  de  chimie  respiratoire  pure  qu'y  s'y  accomplissent. 

Nos  idees  actuelles  nous  font  consid^rer  dans  I'acte  respiratoire,  I'oxy- 
gene  comme  base  de  I'aUmentation  sanguine. 

Y  a-t-il  un  moment  ou  la  proportion  de  ce  gaz  par  rapport  aux  autres 
Elements  de  I'air,  parvient  a  deranger  I'^conomie  respiratoire?  II  est  in- 
contestable que  des  accidents  par  asphyxie  peuvent  se  produire,  si  dans  un 
espace  herm^tiquement  clos,  on  diminue  ou  on  augmente  notablement  la 
proportion  d'oxygene.  La  tension  de  ce  gaz  ne  peut  ni  s'abaisser,  ni  d6- 
passer  un  certain  chiffre  sans  devenir  dangereux.  Ces  conditions  ne  sont 
realisables  du  reste,  que  dans  des  experiences  de  laboratoire,  ou  tout-a-fait 
accidentellement  dans  la  Nature.  Dans  une  atmosphere  libre,  elles  ne  se 
pr6sentent,  pour  ainsi  dire,  jamais.  Que  Ton  soit  au  bord  de  la  mer  ou  sur 
de  hautes  montagnes,  I'echelle  des  proportions  entre  I'azote  et  I'oxygene 
reste  dans  un  rapport  tel  que  I'organisme  s'y  acclimate. 

De  nombreuses  experiences,  il  semble  r^sulter  que  les  variations  con- 
statees  couramment  dans  nos  habitations  ordinaires,  sont  h  peine  sensibles. 
II  est  etabli  que  dans  les  conditions  ou  sont  la  plupart  de  nos  logements,  le 
volume  d'oxygene  ne  subit  pas  de  diminution  sensible  du  fait  de  ses  occu- 
pants. 

Comme  pour  I'oxygene,  I'acide  carbonique  est  en  rapport  avec  la  tension 
de  I'atmosphere  et  non  avec  le  volume  qu'il  occupe. 

634 


DE   l'aIR    confine    ET   DE   LA   TUBERCULOSE. — REY.  535 

C'est  la  difference  de  tension  entre  I'oxygene  dissous  dans  le  sang  et  celui 
contenu  dans  Tatmosphere  qui  produit  I'exhalaison  pulmonaire. 

*        *         *         * 

II  faut  en  conclure  que  les  redoutables  dangers  de  I'air  confine  surtout  en 
ce  qui  concerne  la  contagion  Tuberculeuse,  ne  sont  pas  le  r^sultat  des  pro- 
portions d'oxygene,  d'azote,  et  d'acide  carbonique,  compar6es,  a  celles  de 
I'air  lib  re.  A  tensions  egales  entre  ces  atmospheres,  ces  proportions  varient 
relativement  peu. 

La  veritable  cause  doit  etre  recherchce  dans  la  diffusion  dans  Vatmosphere 
confince,  de  la  maticre  organique  rejetee  par  les  poumons,  et  surchargee  de 
vapeur  d'eau.  Genee  par  la  presence  de  ce  toxique  violent,  Taction  physio- 
logique  est  peu  a  peu  compromise  par  les  effets  morbides  que  produisent  ces 
matieres  en  suspension.  Juxtaposee  ou  dissoute  en  partie  dans  les  flancs 
microscopiques  des  goutelettes  de  vapeur  d'eau  expectorees,  cette  matiere 
organique  ne  tarde  pas  a  faire  sentir  ses  effets. 

Elle  crce  un  veritable  marecage  aerien  dans  lequel,  sans  nous  en  apercevoir, 
nous  sonuncs  peu  a  peu  complHenient  noyes.  C^est  un  milieu  de  culture  oil 
les  germes  ne  tardent  pas  a  pulluler  a  I'infini. 

Tres  variable  en  quantite  et  en  qualite,  suivant  les  individus,  la  toxine 
humaine  est  dans  un  rapport  etroit  avec  I'exhalaison  d'acide  carbonique. 
L'azote,  par  sa  masse  meme,  qui  forme  les  f  de  I'atmosphere  totale  et  en 
constitue  I'element  gazeux  le  plus  stable,  y  joue  le  role  capital,  an  effet,  de 
substratum  naturel  a  tons  les  germes  organiques  inoffensifs  ou  patogenes. 

Le  seul  poison  de  Vair  confine,  qui  s'accumule  lentement  dans  Vinterieur  des 
habitations  etjlnit  par  s'incruster  sur  tons  les  objets  quHl  contient,  est  la  matiere 
organique.  Produit  de  combustions  intimes,  dechet  empoisonne  d'actions 
biologiques  qui  nous  echappent  completement  et  restent  impenetrables,  il 
faut  a  tout  prix  le  combattre  et  I'espulser.  La  seule  hypothese  plausible 
que  Ton  puisse  faire  sur  I'origine  de  cette  matiere  est  de  la  considerer  comme 
etant  surtout  composee  de  toxines  dont  se  dcbarrassent  tons  les  infiniments 
petits  qui  sont  en  nous,  sous  Taction  respiratoire  des  poumons;  ce  rejet  au 
dehors  se  fait  avec  une  merveilleuse  regularite  et  une  energie  insoupQonn^e 
jusqu'ici. 

Ces  detritus  sont  d'autant  plus  redoubtables  que  suivant  les  conditions 
de  sante  et  de  maladie  de  Tindividu,  ils  acquierent  une  nocivit^  autrement 
plus  virulente  que  ceux  provenant  des  reins,  du  foie  ou  de  Tdlaboration  in- 
testinale.  Cette  toxine  v^hiculee  ou  dissoute  par  la  vapeur  d'eau,  se  diffuse 
sous  Teffet  de  la  tension  de  Tair  et  impregne  toute  la  masse  gazeuse  respira- 
toire. L'oxygene  lui,  se  renouvelle  au  fur  et  a  mesure  de  sa  consommation 
sous  la  pression  extcrieure  qui  p(5netre  de  part  en  part  Thabitation  et  k 
laquelle  rien  ne  pent  s'opposer.  L'acide  carbonique  s'^limine  de  lui-meme. 
La  masse  d'azote  inerte  qui  ne  subit  d'autre  influence  que  celle  des  differences 


536  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

de  temperature  devient  alors  le  support  forc6  de  toutes  les  impuretes,  des 
produits  solubles  de  la  vapeur  d'eau,  des  germes  organiques  de  tout  genre, 
des  poussieres  de  toute  nature.  L'oxygene  etant  le  destructeur  de  toute 
putrefaction  organique,  c'est  I'azote  qui  est  le  veritable  foyer  de  culture. 

L'enveloppe  d'air  que  la  chaleur  du  corps  emprisonne  dans  nos  vetements 
se  charge  aussi  de  tous  les  dechets  de  la  transpiration  cutan^e,  qui  a  beau- 
coup  d'analogie  avec  celle  des  poumons.  Si  par  une  aeration  bien  comprise 
ces  dechets  ne  sont  pas  rapidement  enleves  autour  de  notre  corps,  ils  se  trans- 
forment  en  germes  nocifs  et  n'attendent  qu'une  occasion  favorable  pour 
penetrer  dans  Torganisme  par  toutes  les  portes  qui  peuvent  s'offrir. 

La  souillure  de  I'azote  semble  done  n^cessiter  la  purification  des  atmos- 
pheres confines. 


HIGIENE  ESCOLAR  EN  EL  ECUADOR. 
By  Dr.  M.  Jigon  Bello, 

Quito,  Ecuador. 


"A  nuestro  juicio,  la  medicina,  no  es  tan  elevada  6  importante,  sino, 
porque  en  sus  relaciones  con  los  pueblos  y  los  individuos  ella  regula  los  prin- 
cipios  que  fisica  y  moralmente,  hacen  la  fuerza  de  las  Naciones  y  la  salud  de 
cada  uno  en  particular." — Bouchu. 

Tomando  como  base  esta  doctrinal  sentencia,  abordare  en  la  presente 
publicacion,  un  estudio  para  mi,  de  vital  interfe,  que  dice  la  salud,  la  longevi- 
dad,  el  mejoramiento  de  nuestra  raza,  por  hoy  y  sucesivamente  enclenque, 
valetudinaria  y  cuya  vida  media  decrece  dia  d  dia;  me  ocupar^  por  tanto  de 
la  manera  como  es  tenida  y  educada  la  ninez  que  afluye  a  la  Escuela,  y  cuyas 
pesimas  condiciones  de  educaciom  son  causa,  sino  unica,  al  menos  la  prin- 
cipal del  deterioro  orgdnico,  de  la  degeneraci6n,  no  dire  solo  fisica  sino  aun 
moral  que  con  pesar  se  nota  aqueja  a  la  generacion  actual. 

Sabido  es,  que  el  niiio  es  ser  cuyos  organos  en  via  de  desarrollo,  exijen 
cuidados  y  medio  adecuado  para  alcanzar  su  completo  y  perfecto  desenvolvi- 
miento,  a  manera  que  un  vegetal  que  germina,  requiere  cultivo  y  labor  es- 
merada,  para  cosechar  fruto  robusto  y  sazonado.  Si  se  hace  caso  omiso, 
de  la  parte  material  del  nino,  si  no  le  damos  medios  apropiados  a  su  vida  y 
crecimiento,  habremos  perdido  en  flor,  existencias,  quizd  talentos  que  hubie- 
sen  formado  el  orgullo  y  la  felicidad  de  su  patria. 

Para  este  ultimo  resultado,  contribuyen  por  desgracia  dos  factores:  1. 
Una  falsa  idea  y  desmedida  exigencia  de  los  padres:  2,  La  incuria  de  los 
Gobiernos.  Cuanto  a  lo  primero,  es  sabido  que  los  padres  de  un  nino,  creen 
que  este  es  solo  cerebro,  que  no  domina  en  ^1,  sino  el  espiritu,  y  que  ^ste  es 
el  lini  co  al  que  estan  llamados  a  cultivar;  su  unica  ambicion  la  cifran  en 
tener  un  sabio  en  miniatura;  si  posible  les  fuese  ponerlo  d,  la  escuela  desde  el 
instante  que  el  niiio  nace,  no  se  excusarfan  ya  que  su  orgullo  seria  tener  un 
doctor  de  cinco  a  siete  anos;  y  para  conseguirlo,  no  se  paran  en  medio  nin- 
guno:  salud,  robustez  desarrollo  ffsico,  son  factores  secundarios;  sueno,  di- 
gestion, recreo,  son  elementos  daninos;  el  nino  debe  sacrificarlo  todo,  ni 
dormir,  ni  comer,  ni  pasear  si  no  es  con  el  libro,  y  esto  bajo  pena  de  caer  en 
descr^dito,  ante  el  padre,  el  maestro,  y  la  sociedad,  y  merecer  censura  y 
castigo. 

637 


538  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

Por  lo  que  toca  a  lo  segundo,  ningun  Gobierno  se  ha  tornado  la  pensi6n 
de  dictar,  un  reglamento  de  escuelas  que,  guisdo  por  la  razon  y  la  ciencia, 
hubiese  mirado  jjor  la  salud,  desarrollo  y  bienestar  de  la  ninez,  no:  a  mucha 
filantropia  ha  tenido  el  senalar  textos,  y  una  vivienda  cualquiera,  donde  se 
acinen  miles  de  ninos,  d  sacrifiear  su  vida,  a  trueque  de  alguna  instruccion, 
que,  en  tiempos  mas  remotos  la  daba  algun  incUviduo  que,  para  ser  buen 
maestro,  debfa  ser  bien  barbaro  y  tener  como  regla  que :  la  letra  con  sangre 
entra;  deduci^ndose  que  la  educacion  entre  nosotros  ha  sido  un  martirologio 
complete. 

El  programa  de  escuelas  que  ha  existido  y  existe  es  el  siguiente :  Horas  de 
clase  de  6  a.  m.  a  4  p.  m,,  tiempo  en  que  el  nino  como  hecho  de  una  pieza  con 
el  p^simo  banco  que  le  sirve  de  asiento,  no  tiene  libertad  ni  para  mover  una 
pestana,  bajo  pena  de  azotes.  Termina  el  dia,  y  parece  que  cesaria  tan  pe- 
sado  cautiverio,  no :  el  nino  va  a  su  casa,  con  el  deber,  es  decir  con  una  do- 
cena  de  cuadernos,  lo  menos,  unos  de  gramatica,  aritmetica,  geograffa; 
otros  de  matematicas  superiores,  fisica,  quimica,  geologia,  ciencias  publi- 
cas,  etc.,  etc.;  y  de  los  cuales  en  las  cortas  horas  que  deberla  serle  de  descanso, 
unos  debe  aprenderlos  de  memoria  y  otros  escribirlos  de  cualquier  manera 
y  en  variedad  de  letras:  despu^s  de  pasada  media  noche  en  cumphr  con  el 
deber,  se  entrega  por  fin  el_  nino  a  un  sueno  turbado  por  la  pesadilla  del 
maestro,  y  vuelve  a  las  cinco  de  la  maiiana  d  em  prender  su  pesada  tarea  de 
las  letras,  y  se  encamina  A  la  prisi6n,  cargado  de  una  biblioteca.  Esto 
ultimo,  sin  exageraci6n,  pues  al  registrarse  la  cartera  de  uno  de  nuestros  esc 
olares  no  quedarfa  sin  encontrarse  todas  las  obras  escritas  en  humanidades, 
literatura  y  ciencias.  Al  hallarlas,  cualquiera  asombrado  exclamaria  que, 
nino  tan  instruido  y  el  maestro  la  lumbrera  de  la  pedagogia,  ensena  lo  que 
no  es  creible';  y  el  nino,  diria  yo  de  puro  sabio  no  tardara  en  ver  a  Dios,  pues 
consumido  en  su  organismo,  y  llegado  A  la  suma  perfectibilidad,  a  fuer  de 
martirio,  estuidio  y  ciencia  se  hara  digno  de  el. 

Pero,  y  la  sociedad  para  la  que  se  le  educa,  y  d  la  que  tiene  que  ser  util? 
Ganard  me  responderan  los  maestros.  Perdera  les  contestare  yo,  y  la  prueba 
es  sencilla:  Las  concepciones  del  espiritu,  necesitan  de  un  medio  para  sus 
manifestaciones,  este  es  el  cerebro,  y  su  mayor  6  menor  perfeccionamiento 
orgdnico,  decide  del  grado  de  capascidad  intelectual  de  cada  individuo;  un 
cerebro  bien  organizado  es  elque  nos  da  los  sabios,  y  los  incompletamente 
desarrolados,  los  idiotas,  pues  el  espiritu  a  semejanza  de  un  foco  luminoso, 
trasmite  su  luz,  tanto  mas  nitida  y  brillante,  cuanto  mds  adecuado  y  perfecto 
es  el  medio  por  el  que  atraviesan  sus  rayos.  Ahora,  el  desarrollo  y  perfec- 
cionamiento de  la  masa  encefalica,  es  sinergico  del  que  tenga  el  organismo 
en  general,  y  relativo  a  aquel,  el  de  la  inteligencia;  luego,  un  individuo  debil, 
an^mico,  desgastado,  sera  un  neuropata,  visionario,  ilusionado  6  cosa  pare- 
cida,  mas  no  un  sabio,  y  para  tenerlo  tal,  se  hace  menester  que  el  desarrollo 


HIGIENE   ESCOLAR   EN    EL    ECUADOR. — BELLO.  539 

organico  del  niiio,  sea  complete,  que  su  salud  y  bienestar  sean  cabales,  en- 
tonces  ese  cerebro  sera  apto  para  exteriorizar  las  operaciones  del  espiritu, 
con  la  lucidez  propia  a  lo  adecuado  de  su  medio.     Muy  sabiamente  dijeron: 

Bacon  "  Para  el  alma  humana,  un  cuerpo  sano  es  un  huesped,  y  un  cuerpo 
enfermo  un  carcelero.  Una  salud  inalterable  liga  estrechamente  el  alma  al 
cuerpo." 

J.  J.  Rousseau :  "  Las  operaciones  del  cuerpo  y  el  espiritu  deben  marchar 
de  concierto  y  la  una  dirijir  a  la  otra." 

Platon  El  mas  agralable  espectaculo  seria  contemplar  la  perfeccion 
del  alma  y  la  del  cuerpo,  unidas  entre  ellas  en  perfecta  armonia." 

Persiguiendo  este  fin,  toda  nacion  culta  y  civilizada  todo  Gobiemo 
solicito  por  el  incremento,  salud,  robustez  y  bienestar  de  zu  pais,  no  ha  omi- 
tido  medio  alguno  para  propender,  a  la  par  que,  al  cultivo  de  la  inteligencia, 
al  desemvolvimiento  y  desarrollo  material  del  nirio,  buscandose  un  sistema 
de  ensenanza  que  sin  fatigar  el  espiritu,  haga  mas  fructuosa  la  instruccion 
colocandole  en  un  medio  que  favorezca  su  salud,  dotandole  de  lo  necessario 
para  que  d,  la  vez  que  se  atienda  a  su  desarrollo  fisico  se  impida  su  deterioro, 
y  las  mil  deformaciones  con  siguientes  a  una  escuela  mal  tenida  d  deficiente 
en  su  menaje. 

Para  conseguirlo,  se  me  preguntara  Porqu6  medios  puede  optarse? 
Respondo : 

1.  Dotando  a  las  escuelas  de  locales  amplios,  espaciosos,  ventilados,  con 
pisos  y  paredes  revestidos  materiales  de  que  sin  producir  polvo  sean  sus- 
ceptibles  de  lavados;  acondicionados  de  manera  que  aun  la  luz  penetre  en 
ellos  sin  incomodar  6  daiiar  la  vista  del  educando :  con  un  menaje  apropiado 
a  la  talla  de  los  alumnos,  de  suerte  que  sentados  y  entregados  a  sus  facnas, 
su  posicion  y  actitud  sean  normales,  para  evitar  incurbaciones  y  deformidades 
ffsicas:  disponiendo  de  huertos  y  jardines  que  proporcionen  a  los  ninos  aire 
puro  y  oxigenado,  que  reintegre  a  su  sangre  el  elemento  de  vida  indispensable 
a  su  edad. 

2.  Imponiendo  a  los  ninos  una  labor  intelectual  proporcionada  a  su 
edad,  constitucion,  temperamento  y  capacidad  para  el  estudio. 

3.  Dividiendo  cientificamente  su  trabajo  mental  con  otro  ffsico,  en  el 
que  descansando  el  cerebro,  se  desarrolle  el  sistema  muscular  por  medio  de 
una  gimnasia  metodica,  bien  calculada  y  dirijida. 

En  nuestras  escuelas,  ninguna  de  estas  condiciones  se  Uena,  y  menos  la 
ultima :  gimnasios  son  desconocidos,  y  si  alguna  vez  se  tiene,  es  un  trapecio, 
al  que  sin  ejercicio  ninguno  preliminar  y  bien  dirijido,  se  entrega  brusca  y 
barbaramente  a  un  nino,  y  del  que  no  reporta  en  muchas  ocasiones,  mas 
beneficio  que  una  hernia,  6  una  caida,  que  le  ocasiona  lesiones,  que  le  alec- 
cionan  para  no  volver  d  6\  jamas. 

En  resumen,  entre  nosotros,  el  niiio  es  solo  un  martir  del  anhelo  de  sus 


540  SIXTH  INTERNATIONAL  CONGRESS  ON  TUBERCULOSIS. 

padres  y  del  afan  cientifico  de  su  maestro,  quien  linicamente,  se  propone 
hacer  de  su  discipulo  un  Salomon,  para  quien  son  inoficiosos  los  cursos  de 
ensenanza  secundaria  y  superior,  sin  jamas  preocuparse  de  la  situacion,  ex- 
tension orientacion  del  establecimiento;  forma  de  la  clase,  su  luz,  aireacion, 
ventilaci6n,  numero  de  educandos  en  relacion  a  su  capacidad;  naturaleza  del 
moviliario,  material  escolar,  tal  como  la  clase  de  papel,  caracteres  y]disposi- 
cion  tipografica  empleada,  distribucion  y  duraci6n  del  tiempo  de  estudio, 
recreo,  gimnasia,  etc,  etc,  de  suerte  que  al  leer  y  revisar  las  monografias 
europeas  que  tratan  de  este  ramo,  y  ver  el  anhelo  y  solicitud  que  se  desplega 
por  la  nifiez,  causa  pesar  el  recordar  y  ver,  como  se  nos  ha  educado  y  educa 
en  todas  las  escuelas  sin  exepcion,  sin  que  esto  se  deba  a  otro  factor,  que  a 
la  injuria  y  dejadez  de  las  autoridades  Uamadas  k  velar  en  este  ramo,  y  a 
proporcionar  los  recursos  que  demanda  la  educacion  bien  comprendida. 

Hoy  el  I.  Concejo  Municipal,  que  desde  el  ano  de  1897,  viene  preocupan- 
dose  de  la  higiene  del  lugar,  trata  de  implantar  como  en  la  Escuela  Municipal 
Sucre,  algo  que,  proporcionalmente  a  sus  escasos  recursos,  remedie  la  anti- 
gua  antihigienica  educacion  escolar,  y  para  ello  aun  tiene  colocados,  algunos 
aparatos  de  gimnasia,  y  pedidos  a  Europa  otros  de  traccion  elastica,  a  fin  de 
que  el  Profesor  nombrado  para  el  caso,  organice  este  nuevo  y  necesario  ejer- 
cicio  hiji^nico  en  la  mencionada  escuela,  la  que,  no  dudo  sera  modelo  para 
las  demas;  y  no  vacilo  en  creer  que,  tambi^n  el  S.  Gobierno  secundara  la 
iniciativa  del  I.  Concejo,  y  que,  proporcionando  a  todas  las  escuelas 
nacionales,  locales  adecuados,  provistos  de  todo  lo  que  ha  menester, 
para  una  educacion  en  relacion  con  las  exigencias  y  adelantos  moder- 
nos,  reglamentard,  cientfficamente  la  ensenanza,  marcando  la  edad  en 
que  un  nifio  puede  ser  admitido  k  la  escuela,  condiciones  de  admision 
basadas  en  la  Constitucion  y  salud  del  nifio;  horas  de  estudio  y 
recreo,  naturaleza  de  6ste;  materias  limitadas  de  estudio  que  debe 
cursar;  en  una  palabra,  que  en  cada  escuela,  hara  pr^cticos  todos  los  pre- 
ceptos  cientificos  de  higiene  escolar,  adelanto  €  innovacion  tanto  mas  facil 
de  obtenerla  cuanto  que  en  ramo  de  pedagogia,  nuestro  pais  tiene  maes- 
tros  de  reconocida  notoriedad  y  competencia,  y  que  nada  dejarian  que  desear 
en  punto  a  instruccion  primaria,  si  se  les  diese  para  ser  obedecida,  una  regla- 
mentacion  cientifica  y  razonada;  si  dispusiesen  de  locales,  recursos  y  medios 
adecuados  para  llenar  su  cometido;  y  si  fuesen  bien  dotados,  premiados, 
estimulados,  de  manera  que  el  magisterio  de  ensenanza  primaria,  deje  de 
ser  como  se  dijo:  empleo  de  los  que  no  tienen  oficio,  para  ponerlo  a  la  altura 
que  se  merece  la  sublime  mision  de  instruir,  moralizar  formar  y  colocar  en 
la  escala  que  le  cumple,  al  ser  que  hoy  se  llama  nifio,  y  que,  sin  tales  requisi- 
tos  y  cultura,  no  Uegarla  a  llamarse  hombre,  y  menos  d  formar  los  encantos, 
la  felicidad  y  el  orgullo  de  su  hogar  y  su  patria. 

No  terminare  esta  Ugera  publicacion  sin  encarecer  tambi^n  a  los  padres 


HIGIENE   ESCOLAE   EN    EL   ECUADOR. — BELLO.  541 

de  familia,  se  convenzan  de  la  signiente  verdad  emitida  por  Plutarco,  en 
sus  estudios,  acerca  de  la  educacion  de  los  nifios,  quien  dice :  Conozco  padres 
que  por  demasiado  amor  a  sus  hijos,  son  realmente  sus  enemigos.  Los  hay, 
por  ejemplo,  que  demasiado  celosos  de  su  mas  rapido  progreso,  y  deseosos  de 
verlos  obtener  una  superioridad  notable,  les  sobrecargan  de  un  trabajo  for- 
zado,  cuyo  peso  les  anonada.  Resulta  de  alli  un  desaliento  que  vuelve  odioso 
todo  estudio.  Las  plantas  que  moderadamente  se  rocian,  crecen  facilmente; 
pero  el  agua  en  abundancia  las  ahoga  en  germen.  Asi  tambi^n,  el  alma  se 
nutre  y  fortifica  por  un  trabajo  bien  dirijido,  y  el  exceso  extingue  y  concluye 
sus  mas  excelentes  facultades.  Conviene,  pues,  dar  descanso  a  los  ninos, 
recordando  que  todo  en  la  vida,  esta  dividido  entre  la  accion,  el  trabajo  y 
el  reposo.  Se  vela  durante  el  dla  se  duerme  la  noche.  La  paz  sucede  a  la 
guerra,  la  calma  a  la  tempestad.  Los  dias  de  trabajo,  son  interrumpidos 
por  dias  de  fiesta :  en  una  palabra,  el  descanso  es  la  salsa  del  trabajo,  viendo 
la  prueba  de  ello,  no  solamente  en  los  seres  animados,  sino  aun  en  las  cosas 
insensibles.  Los  arcos  y  las  liras,  tienen  necesidad  de  ser  distendidos  para 
servir  ultimamente.  En  fin,  el  cuerpo  no  se  sostiene  sino  por  el  cambio  de 
sus  menesteres  y  su  nutricion,  y  el  espiritu  por  la  alternativa  de  su  accion 
y  reposo." 

Ojala  este  mal  aliilado  trabajo,  contribuya  al  mejoramiento  de  esta 
descuidada  rama  de  la  higiene,  y  sea  en  beneficio  de  la  niiiez  que  forma  las 
futuras  esperanzas  de  nuestra  Patria, 


SECTION  IV. 


Tuberculosis    in    Children — Etiology,    Prevention, 
and  Treatment  {Continued), 


FOURTH  DAY.     MORNING  SESSION. 

Thursday,  October  1,  1908. 

THE  OPHTHALMIC  REACTION.    CUTANEOUS  REACTION.    LUMBAR 

PUNCTURE. 


The  President,  Dr.  Jacobi,  called  the  Section  to  order  at  ten  o'clock. 

THE  VALUE  AND  RELIABILITY  OF  CALMETTE'S  OPH- 
THALMIC REACTION  TO  TUBERCULIN 

FOR  THE   DIAGNOSIS   OF   TUBERCULOSIS  AND  THE   DIFFER- 
ENTIATION OF  TUBERCULOUS  LESIONS  FROM  OTHER 
DISEASES  IN  INFANTS  AND  YOUNG  CHILDREN. 

By  E.  Mather  Sill,  M.D., 

New  York. 


In  spite  of  the  great  advances  that  have  been  made  in  our  knowledge  of 
the  etiology,  diagnosis,  and  treatment  of  tuberculosis  one-seventh  of  all 
deaths  in  animals  and  man  are  due  to  this  disease,  hence  any  new  and  practi- 
cable method  for  determining  to  a  reasonably  certain  degree  the  presence  or 
absence  of  a  tuberculous  focus  in  the  body  is  hailed  with  the  greatest  enthus- 
iasm. 

Frequency  in  Childhood. — That  tuberculosis  in  infancy  and  childhood 
is  much  more  frequent  than  was  formerly  supposed,  and  that  this  frequency 
increases  regularly  with  the  age,  has  been  shown  by  the  autopsy  records  of 
many  prominent  authorities.     Miiller,  of  Munich,  found  tuberculosis  present 

542 


CALMETTE'S  ophthalmic  reaction. — SILL.  543 

in  40  per  cent,  of  500  children  on  whom  autopsies  were  performed,  and  in  10 
per  cent,  of  these  the  children  died  from  causes  other  than  tuberculosis. 
Of  319  autopsies  reported  by  Holt  at  the  Babies'  Hospital,  14  per  cent,  were 
tuberculous.  These  figures  go  to  show  the  frequency  of  the  disease  in  child- 
hood and  the  difficulty  of  diagnosis. 

That  tuberculous  conditions  are  so  slight  and  obscure  in  many  instances 
as  to  render  diagnosis  by  the  old  methods  impossible  is  instanced  by  the 
experiments  of  Loomis,  who  inoculated  animals  with  the  bronchial  lymph- 
nodes  of  30  persons  dying  from  violence  or  acute  diseases  in  whom  no  evidence 
of  acute  disease  could  be  found  in  any  other  part  of  the  body  at  autopsy,  and 
from  8  of  the  cases  he  produced  tuberculosis  in  the  inoculated  animals. 

Until  recently  there  was  no  means  of  proving  the  presence  of  a  tubercu- 
lous lesion  in  the  body,  and  thus  many  cases  of  children  with  incipient  or 
latent  tuberculosis,  or  with  tuberculosis  in  regions  other  than  the  lungs, 
have  remained  undiagnosed,  or  were  diagnosed  as  other  diseases,  and  im- 
proper or  no  treatment  instituted. 

We  now  have  at  our  disposal  a  fairly  reliable  and  apparently  harmless 
means  of  determining,  with  a  reasonable  degree  of  certainty,  whether  or 
not  a  tuberculous  focus  exists  in  a  given  case.  This  is  the  ophthalmic  reac- 
tion to  tuberculin.  The  important  points  of  value  in  this  new  method  of 
diagnosis  are: 

1.  That  tuberculosis  reacts  to  the  agent. 

2.  That  non-tuberculous  cases  do  not  show  this  reaction. 

3.  That  the  test  has  an  effect  upon  old  cases  of  healed  tuberculosis. 
Method  of  Administration. — Our  method  of  administration  has  been 

the  same  as  that  of  Calmette,  namely,  one  drop  of  a  1  per  cent,  sterile  solution 
of  the  precipitated  tuberculin  being  instilled  into  one  eye,  the  lower  lid  being 
drawn  well  down  and  held  for  one  minute  after  the  instillation,  so  that  the 
tuberculin  is  thoroughly  diffused  over  the  eyeball  and  conjunctiva.  The 
same  eye  should  not  be  used  for  more  than  one  test,  as  it  becomes  sensitized, 
and  therefore  a  second  instillation  in  the  same  eye  is  of  no  diagnostic  value. 
(The  test  should  not,  of  course,  be  used  in  a  diseased  eye.)  The  lower  lid 
is  drawn  down,  and  the  conjunctiva  and  inner  canthus  are  examined  every 
hour  or  two,  and  the  time  and  amount  of  reaction  noted.  Reactions  varied 
in  their  time  of  appearance  from  three  to  sixteen  hours  after  instillation, 
but  in  a  few  cases  the  reaction  did  not  occur  for  from  twenty-four  to 
forty-eight  hours,  and  in  these  cases  it  sometimes  continued  for  several 
days. 

Occasionally  slight  discomfort  and  a  sensation  as  of  a  foreign  body  in 
the  eye  were  experienced,  but  in  the  majority  of  cases  no  subjective  symp- 
toms were  present.  Usually  a  congestion  of  the  palpebral  and  ocular  con- 
junctiva occurred  in  a  few  hours,  and  the  caruncle  was  hyperemic  and 


544  SIXTH   INTERNATIONAL  CONGRESS   ON   TUBERCULOSIS. 

covered  in  some  cases  with  a  fibrinous  exudate.  Redness  of  the  conjunctiva 
was  not  always  present.  As  the  reaction  advanced  lacrimation  occurred, 
and  a  fibrinous  exudate  resembhng  pus  collected  at  the  inner  canthus. 
The  maximum  of  intensity  was  reached  in  from  six  to  twelve  hours.  The 
patients  did  not  complain  of  pain,  but  occasionally  of  a  slight  burning  in  the 
eye.  The  conjunctivitis  usually  showed  signs  of  abatement  in  from  eighteen 
to  thirty-six  hours,  and  a  case  lasting  ten  days  was  the  exception. 

Variety  of  Tuberculous  and  Other  Conditions  Tested. — ^The  follow- 
ing diseases  were  tested  for  the  ophthalmic  reaction:  (1)  Pulmonary  tuber- 
culosis; (2)  tuberculous  glands  of  the  neck;  (3)  tuberculous  peritonitis; 
(4)  tuberculous  bone  diseases  of  various  kinds;  (5)  pertussis;  (6)  lobar 
pneumonia;  (7)  bronchopneumonia;  (8)  bronchitis  (acute  and  chronic); 
(9)  asthma;  (10)  rheumatism;  (11)  chorea;  (12)  nephritis  (acute,  following 
scarlatina);  (13)  endocarditis;  (14)  enteritis;  (15)  gastro-enteritis;  (16) 
malnutrition;  (17)  marasmus;  (18)  anemia;  (19)  rickets;  (20)  congenital 
syphilis;  (21)  catarrhal  jaundice. 

Some  observers  have  found  that  the  ophthalmic  reaction  is  present  in 
congenital  S3^hilis  and  rickets,  but  in  my  experience  with  these  diseases, 
I  have  never  seen  a  positive  reaction  except  when  complications  existed. 

The  14  cases  tested  were  those  clinically  tuberculous,  which  included 
pulmonary  tuberculosis  where  the  bacilli  were  present,  tuberculous  peri- 
tonitis, tuberculous  glands  of  the  neck,  and  tuberculous  bone  disease;  all 
gave  positive  reactions. 

The  very  suspicious  cases  included  those  with  suspicious  signs  in  the 
chest,  those  with  chronic  bronchitis,  with  malnutrition  and  anemia,  with 
chronically  enlarged  or  suppurating  glands  of  the  neck,  and  those  in  whom 
there  was  a  slight  intermittent  fever  that  could  not  be  accounted  for.  Of 
these,  13,  or  90  per  cent.,  gave  positive  reactions.  Less  suspicious  cases 
were  those  with  anemia,  malnutrition,  enlarged  cervical  glands,  or  chronic 
bronchitis;  also  those  showing  a  family  history  of  tuberculosis,  and  in  whom 
adenoids,  hypertrophied  tonsils,  and  possibly  indefinite  symptoms  that 
might  point  to  a  tuberculous  condition  were  present.  Of  these,  there  were 
101,  with  18  positive  reactions.  The  age  of  the  children  tested  was  from 
three  months  to  ten  years,  and  the  youngest  that  gave  a  positive  reaction 
was  five  months  old.  The  reactions  that  occurred  in  the  infants  were  all 
mild.  Of  the  218  cases  tested,  45  were  positive  and  173  negative.  There 
were  8  severe  reactions  and  37  mild  ones.  In  a  number  of  cases  a  second 
test  was  made  in  the  other  eye,  and  it  was  found  that  all  cases  that  reacted 
to  the  first  test  reacted  also  to  the  second.  Conversely,  cases  that  did  not 
react  to  the  first  test  did  not  react  to  the  second.  Practically  all  those 
giving  positive  reactions  showed  signs  indicating  the  presence  of  tuberculosis 
in  some  form. 


CALMETTE's   ophthalmic  reaction. — SILL.  545 

Of  54  cases  under  one  year,  9  were  positive. 

Of  63  cases  from  one  to  three  years,  15  were  positive. 

Of  38  cases  from  three  to  six-  years,  7  were  positive. 

Of  63  cases  from  six  to  ten  years,  14  were  positive. 

All  that  were  found  clinically  to  be  tuberculous  gave  positive  reactions. 
Of  the  very  suspicious  cases,  90  per  cent,  gave  a  positive  reaction;  18  per 
cent,  of  the  less  suspicious  cases  gave  a  positive  reaction;  and  of  the  89  cases 
with  slight  ailments  and  other  diseases,  none  gave  a  positive  reaction. 

Schick,  after  exhaustive  experimental  work,  believes  that  a  local  reaction 
is  less  likely  to  fail  than  a  general  constitutional  reaction,  and  says  that  in 
no  case  where  tuberculosis  has  been  excluded  has  a  local  reaction  been  present. 

Comby  subjected  132  infants  to  the  ophthalmic  reaction;  of  these,  62 
reacted  and  70  failed  to  react.  In  4  of  those  that  reacted  the  autopsy  con- 
firmed the  diagnosis  of  tuberculosis.  In  6  cases  that  did  not  respond  to  the 
test  autopsy  showed  entire  absence  of  tuberculous  lesions. 

Barney  and  Brooke  tested  321  soldiers,  including  250  tuberculous  cases, 
and  got  98  per  cent,  of  reactions  in  active  cases,  23  per  cent,  in  apparently 
cured  cases,  and  10  per  cent,  in  non-suspects.  This  would  seem  to  indicate 
that  the  reaction  is  dependent  upon  the  tubercle  poison  in  the  body.  The 
same  observers  consider  that,  in  general,  the  diagnostic  value  of  the  ophthal- 
mic reaction  is  as  great  as  that  of  the  Widal  test  in  typhoid  fever. 

The  reaction  is  of  special  value  in  diagnosis  where  slight  signs  at  the 
apex  of  the  lung  exist,  no  bacilli  being  present  in  the  sputum,  or  where  no 
sputum  is  obtainable.  It  is  of  value  also  in  cases  in  which  the  lesion  is 
elsewhere  than  in  the  lungs,  as,  for  instance,  in  the  bones,  glands,  etc. 

The  test  may  indicate  clinically  active  or  clinically  inactive  tuberculosis, 
and  thus,  although  a  tuberculous  focus  may  be  present  in  the  body  it  may 
be  inactive,  and  the  patient  may  be  suffering  from  another  disorder  or  be 
apparently  well. 

We  know  that  tuberculosis  in  infancy  and  childhood  is  largely  a  disease 
of  the  lymph-nodes,  and  in  this  respect  and  in  many  other  ways  it  differs 
from  that  seen  in  adult  life,  and  is  more  difficult  of  diagnosis.  We  know 
also  that  virulent  bacilli  may  be  present  during  life  and  yet  no  lesions  be 
found  at  autopsy. 

As  with  the  adult,  so  it  is  with  the  child:  the  earlier  the  diagnosis  is  made 
and  the  earlier  treatment  is  instituted,  the  better  will  be  the  ultimate  result. 

In  conclusion  I  would  say  that  the  ophthalmic  reaction  is  a  most  valuable 
and  reliable  aid  to  the  diagnosis  of  tuberculosis  in  children  in  its  various 
and  early  forms,  and  one  that  is  safe  when  used  with  care.  While  this  test 
is  not  infallible,  and  should  never  take  the  place  of  a  physical  examination, 
it  is  often  more  accurate  than  the  ear  or  percussing  finger  in  early  pulmonary 

VOL.   11 — 18 


546  SIXTH   INTERNATIONAL  CONGRESS    ON   TUBERCULOSIS. 

cases,  and  by  demonstrating  a  negative  result,  is  far  more  satisfactory  than 
a  negative  sputum  examination. 

Although  a  few  cases  have  been  reported  of  permanent  injury  to  the  eye 
or  prolonged  inflammation  of  the  conjunctiva,  these  occurrences  have  been 
exceedingly  rare,  and,  taking  into  consideration  the  fact  that  this  test  has 
been  used  with  safety  in  thousands  of  cases,  the  few  ill  results  may,  probably, 
be  due  to  errors  in  technic,  the  test  having  been  used  in  a  diseased  eye. 

The  ophthalmic  reaction  is  a  simple  method  of  diagnosis  that  any  prac- 
tising physician  can  carry  out,  making  it  possible  for  him  to  confirm  or 
exclude  a  diagnosis,  with  no  danger  of  affecting  a  tuberculous  lesion  or 
causing  constitutional  symptoms. 


El  Valor  de  la  Prueba  Of  talmica  de  Calmette  en  los  Enf  ermedades  de  los 

Nines. — (Sill.) 
Metodo  de  administracion  y  solucion  empleada. 

Grado  de  la  reaccion  de  la  conjuntiva.     Edad  de  los  niiios.     Variedad 
de  las  pruebas  heshas  en  casos  de  tuberculosis  y  otras  afecciones. 
Algunas  formas  aparentes. 

Concepto  herroneo  de  la  reaccion.     El  valor  de  la  reaccion  en  el  diag- 
n6stico  y  el  diagnostico  diferencial.     Ventajas  de  la  reaccion  of  talmica. 
La  reaccion  cutanea  de  von  Pirquet. 


Reaction  ophthalmique :  sa  Valeur  pour  le  Diagnostic  chez  les  Nourrissons 
et  les  jeunes  Enf  ants. — (Sill.) 
Methode  d'administration,  solution  employee.  Quantite  n^cessaire 
pour  la  reaction  conjonctivale.  Age  des  enf  ants.  Experiences  sur  les 
differences  de  reaction  entre  les  cas  de  tuberculose  et  les  autres  maladies. 
Quelques  fausses  informations  concernant  cette  methode.  Valeur  de  la 
methode  comme  aide  dans  le  diagnostic  et  dans  le  diagnostic  differentiel. 
Avantages  de  la  methode  conjonctivale  sur  la  reaction  cutanee  de  von  Pirquet. 


Der  Wert  und  die  Anwendbarkeit  von  Calmettes  Ophtalmo-Reaktion  f  iir 
die  Diagnose  von  Krankheiten  bei  jungen  Kindern. — (Sill.) 
Methode  der  Anwendung  und  verwendete  Losung.  Intensitat  der 
conjunctivalen  Reaktion.  Alter  der  Kinder.  Versuche  liber  tuberkulose 
und  andere  Zustande  in  Bezug  auf  ihre  Verschiedenheit.  Einige  der  frii- 
heren  anscheinend  unrichtig  beurteilt  in  Bezug  auf  den  Versuch.  Der 
Wert  des  Versuchs  als  ein  Hilfsmittel  fiir  Diagnose  und  Differenzialdiag- 
nose.  Vorziige  des  Conjunctival  versuchs  gegeniiber  der  von  Pirquet'schen 
cutanen  Reaktion. 


THE  CUTANEOUS  AND  OPHTHALMIC  TUBERCULIN 

TESTS  IN  INFANTS  UNDER  TWELVE 

MONTHS  OF  AGE. 

By  Henry  L.  K.  Shaw,  M.D., 

Clinical  Professor  of  Diseases  of  Children,  Albany  Medical  College,  Albany  N.  Y 


A  working  knowledge  of  clinical  and  laboratory  aids  to  diagnosis  is 
essential  to  the  conscientious  practice  of  medicine.  The  laity  is  fast  be- 
coming educated  to  the  fact  that  a  correct  diagnosis  is  an  essential  and  a 
necessary  preliminary  to  successful  treatment.  The  interest  aroused  by 
any  new  method  of  diagnosis  or  clinical  test  demonstrates  the  earnestness 
with  which  the  profession  aims  to  secure  a  correct  diagnosis.  In  no  disease 
perhaps  is  an  early  diagnosis  more  important  and  more  difficult  to  establish, 
especially  in  early  childhood,  than  in  tuberculosis.  The  earlier  the  diagnosis 
is  made  and  proper  treatment  instituted,  the  greater  is  the  chance  of  recovery. 

In  incipient  cases  physical  examination  reveals  little  except  to  skilled 
observers.  The  presence  of  tubercle  bacilli  is  detected  only  when  the  disease 
is  well  established,  and  it  is  with  great  difficulty  that  the  sputum  can  be 
obtained  from  infants  and  young  children.  Cytodiagnosis,  serum  reaction, 
and  the  opsonic  index  require  skilled  laboratory  workers.  The  subcutaneous 
injection  of  tuberculin  has  been  relied  upon  by  many,  but  this  procedure  is 
open  to  criticism  and  will  never  become  popular.  In  making  the  test,  a 
hospital  and  trained  nurses  are  required,  and  it  is  not  justifiable  in  a  routine 
examination. 

In  April,  1907,  von  Pirquet,  of  Vienna,  published  the  results  obtained 
from  cutaneous  vaccination  with  tuberculin.  He  found  a  characteristic 
reaction  in  tuberculous  individuals,  and  formally  announced  the  discoveiy 
of  the  cutaneous  tuberculin  test.  About  a  month  later  Wolff-Eisner,  of 
Berlin,  inspired  by  von  Pirquet,  published  the  results  obtained  from  instill- 
ing a  drop  of  a  weak  solution  of  tuberculin  on  the  conjunctival  mucous 
membrane.  He  found  a  constant  and  specific  reaction  in  tuberculous  sub- 
jects, and  named  it  the  conjunctival  tuberculin  reaction.  A  month  after 
the  publication  of  Wolff-Eisner's  discovery,  Calmette,  of  Paris,  published 
a  series  of  similar  experiments,  but  undertaken  independently,  with  identical 
results.     He  employed  the  term  ophthalmic  test.     Moro,  of  Munich,  recently 

547 


548  SIXTH   INTERNATIONAL   CONGRESS    ON   TUBERCULOSIS. 

found  that  he  could  obtain  a  specific  reaction  on  the  skin  of  tuberculous 
individuals  by  simply  rubbing  in  an  ointment  containing  tuberculin.  This 
he  termed  the  percutaneous  test.  These  tests  all  depend  on  the  local  effect 
of  tuberculin  on  the  tissues,  and  the  vast  amount  of  literature  that  has 
appeared  in  the  past  twelve  months  shows  how  eagerly  the  medical  profession 
has  grasped  at  a  simple,  harmless,  and  inexpensive  method  of  obtaining  an 
early  diagnosis  in  that  all  too  frequent  disease,  tuberculosis. 

Pirquet  employed  the  cutaneous  vaccination  on  147  infants  under  three 
months  of  age  and  had  no  reaction.  Of  64  vaccinated  from  the  third  to  the 
sixth  month,  3  reacted  positively.  He  concludes,  as  a  result  of  his  experi- 
ments, that  the  reaction  is  not  common  or  specific  in  the  first  year  of  life, 
but  becomes  more  frequent  as  the  child  grows  older.  Sperk,  in  the  Escherich 
clinic,  vaccinated  159  infants  under  five  months  of  age  with  no  reaction. 
Aronade  vaccinated  47  infants  under  twelve  months  of  age,  and  one  infant 
reacted  who  was  suffering  from  tuberculosis  of  the  knee.  Forty  of  these 
babies  were  suffering  from  various  disorders,  and  only  7  were  healthy. 
Rietschel  had  only  one  positive  reaction  in  80  infants  under  twelve  months, 
and  that  was  in  a  clinical  case  of  tuberculosis.  Two  other  infants  had  un- 
doubted tuberculosis,  but  they  gave  no  reaction  either  to  the  cutaneous  or 
to  the  subcutaneous  tests.  Faludi  vaccinated  195  new-born  infants  and  their 
mothers  with  a  25  per  cent,  solution  of  tuberculin,  and  obtained  126  positive 
reactions  in  the  mothers  and  not  a  single  reaction  in  the  babies.  Prouff 
and  Petit  vaccinated  54  nursing  babies,  among  whom  were  those  of  12 
mothers  who  gave  a  positive  reaction.  Peer  vaccinated  70  infants  under 
sLx  months  with  no  reactions,  and  42  from  six  to  twelve  months  with  3 
reactions.  One  of  these  was  clinically  a  case  of  tuberculosis,  and  2  were 
considered  suspicious.  Langstein,  in  100  vaccinations  under  twelve  months 
of  age,  had  only  one  positive  reaction.  This  baby  died,  and  the  autopsy 
showed  tuberculosis.  Cannata  had  no  reaction  in  70  infants  under  six 
months  of  age,  and  3  out  of  42  infants  from  six  to  twelve  months  of  age. 
Briickner  obtained  3  positive  reactions  out  of  31  infants  vaccinated,  and 
these  all  gave  physical  signs  of  tuberculosis.  Engel  and  Bauer  report  6 
positive  reactions  in  48  infants.  Five  of  these  showed  no  clinical  signs  of 
tuberculosis  and  the  subcutaneous  tuberculin  test  was  negative. 

Many  of  the  authors  do  not  specify  in  their  reports  the  exact  age  of  the 
children.  Czerny  stated  that  all  the  vaccinations  made  on  infants  in  his 
clinic  under  one  year  of  age  were  negative,  but  the  number  of  tests  is  not 
given.  Baginsky,  in  a  discussion,  said  that  no  infant  in  his  hospital  had 
reacted  to  the  cutaneous  test.  All  the  obseiTations  referred  to  were  made 
with  the  cutaneous  test,  and  no  detailed  account  of  the  ophthalmic  test  in 
young  infants  can  be  found  in  the  literature.  Comby  made  a  series  of  ex- 
periments, and  concluded  that  the  age  of  the  child  materially  influenced 


CUTANEOUS   AND    OPHTHALMIC  TESTS   IN   INFANTS. — SHAW.  549 

the  occurrence  of  the  ophthalmic  reaction.  Under  one  year  of  age  he  was 
unable  to  obtain  any  reaction  either  in  tuberculous  or  in  non-tuberculous 
cases.  Von  Pirquet,  Wolff-Eisner,  and  Moro  all  use  and  advocate  the  em- 
ployment of  tuberculin  prepared  from  the  human  type  of  tubercle  bacilli, 
whereas  Calmette  uses  tuberculin  prepared  from  the  bovine  type.  This  fact 
is  net  generally  appreciated,  as  many  of  the  advertised  preparations  of 
" tuberculin  prepared  according  to  Calmette"  for  the  ophthalmic  test  are 
made  from  tuberculin  of  the  human  tjq^e.  Of  great  interest  in  this  con- 
nection is  the  work  of  Detre,  of  Budapest,  who  claims  the  possibility  of 
a  differential  tuberculin  reaction  to  determine  whether  the  infection  is  of 
human  or  of  bovine  origin. 

The  writer  made  two  series  of  tests  on  infants  under  twelve  months  of 
age  at  St.  Margaret's  House,  Albany.  Tliis  institution  admits  only  infants 
under  twelve  months  of  age,  who  are  sent  there  because  of  sickness,  improper 
feeding,  and  the  like.  The  first  series  of  experiments  were  made  on  47 
infants,  14  of  whom  were  under  five  months  of  age.  A  supply  of  tuberculin 
(human),  especially  prepared  and  donated  by  Dr.  Baldwin,  of  Saranac,  was 
employed,  in  dilutions  of  1:100  and  1:200.  The  1:200  dilution  was  used 
first,  one  drop  being  instilled  in  the  left  eye.  There  was  no  reaction  in  any 
of  the  babies.  Two  weeks  later  a  drop  of  the  1 :  100  dilution  was  instilled 
in  the  same  eye,  with  the  same  result.  Shortly  after  this  a  cutaneous 
vaccination  was  made  on  the  same  infants,  using  tuberculin  (human) 
furnished  by  Professor  Veranus  Moore,  of  Cornell  University.  Only  one 
showed  a  slight  reaction;  this  was  an  old  case  of  empyema  with  a  discharging 
sinus.  The  pus  was  injected  in  a  guinea-pig,  who  died  later  of  tuberculosis. 
It  is  of  interest  to  note  that  the  Baldwin  tuberculin — 1 :  200 — ^gave  a  positive 
result  in  8  older  children  with  known  bone  tuberculosis. 

A  second  series  of  tests  were  made  at  the  same  institution  on  34  infants, 
16  being  under  five  months  of  age.  In  this  series  a  drop  of  a  1  per  cent, 
solution  of  bovine  tuberculin  was  instilled  in  the  left  eye,  and  a  drop  of  a  1 
per  cent,  solution  of  human  tuberculin  in  the  right  eye.  No  reaction  occurred 
in  either  eye.  Vaccinations  were  also  made  with  both  types  of  tuberculin, 
with  no  reaction.  A  drop  of  the  full  strength  of  bovine  tuberculin  instilled 
in  the  eyes  of  4  infants  produced  absolutely  no  irritation. 

The  babies  appeared  to  object  more  to  the  pulling  down  of  the  lower  lid 
and  the  instilling  of  a  drop  of  tubercuUn  in  the  eye  than  to  the  vaccination. 
It  should  be  observed  that  the  crying  that  occurred  in  the  older  infants 
might  possibly  wash  away  the  tuberculin  and  render  the  test  unreliable. 
There  were  no  bad  effects  from  either  test.  None  of  the  81  infants  showed 
any  physical  or  clinical  signs  of  tuberculosis,  and  in  4  who  died  later  no 
evidence  of  tuberculosis  was  found  at  the  autopsy. 

The  results  of  my  experiments  on  81  infants  under  twelve  months  of 


550  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

age  show  that  no  reaction  to  the  ophthalmic  test  follows  the  use  of  either 
human  or  bovine  tuberculin  in  solutions  of  various  strengths.  The  cutaneous 
tests  in  the  same  infants  gave  one  reaction.  Bovine  tuberculin  was  used  in 
34  cases  with  no  reaction. 

The  status  of  both  these  tests  seems  to  be  more  secure,  and  in  older 
children  and  adults  they  are  most  important  aids  to  diagnosis.  In  young 
infants,  however,  they  cannot  be  said  to  be  so  rehable.  Czerny,  Binswanger, 
and  Hamburger  show  that,  of  1002  autopsies  on  infants  under  three  months 
of  age,  tuberculosis  was  found  in  23,  or  2.3  per  cent.;  of  542  autopsies  on 
infants  from  four  to  six  months  old,  62,  or  11.1  per  cent.;  and  of  463  on 
infants  from  seven  to  twelve  months,  92,  or  19.9  per  cent.  The  published 
statistics  show  that  less  than  2  per  cent,  of  all  infants  under  twelve  months  of 
age  react  to  either  test  or  either  type  of  tuberculin. 

The  cutaneous  test  is  simple,  easy  of  application,  and  absolutely  without 
danger.  Its  use  is  preferable  to  the  ophthalmic  test,  a  number  of  instances 
of  injury  to  the  eye  following  this  test  having  been  reported. 


A  REPORT  UPON  ONE  THOUSAND  TUBERCULIN  TESTS 
IN  YOUNG  CHILDREN. 

By  L.  Emmett  Holt,  M.D.,  LL.D., 

Professor  of  Diseases  of  Children  in  The  College  of  Physicians  and  Surgeons  (Columbia  University), 

New  York. 


The  observations  included  in  the  following  report  were  all  made  upon 
ward  patients  at  tlie  Babies'  Hospital.  Very  few  of  the  children  were  over 
three  years  of  age,  the  majority  being  under  two  years.  Nearly  all  the  ob- 
serv^ations  have  been  made  in  the  past  year.  In  the  early  part  of  the  year, 
unless  some  positive  contraindication  existed,  some  test,  most  frequently 
the  eye  test,  was  used  as  a  routine  measure,  in  order  to  determine  whether 
and  under  what  circumstances  reactions  were  obtained  in  healthy  children, 
or  in  those  at  least  presumably  non-tuberculous.  During  the  latter  half 
of  the  period  the  tests  have  been  chiefly  used  when  there  were  some  grounds 
for  suspecting  that  tuberculosis  existed.  Routine  tests  proved  of  consider- 
able value  in  revealing  the  presence  of  tuberculosis  in  cases  not  hitherto 
suspected.  A  positive  reaction  to  the  skin  or  eye  test  was  immediately 
followed  by  a  careful  cUnical  study  of  the  case  to  discover,  if  possible,  any 
other  evidence  of  tuberculosis.  In  a  large  proportion  of  such  patients 
bacilli  were  found  in  the  sputum,  although  in  many  only  after  prolonged 
search  and  repeated  examinations,  thus  establishing  the  accuracy  and  the 
value  of  the  test.  In  many  patients  further  evidence  was  afforded  by  the 
development  of  definite  signs  of  pulmonary  disease. 

The  Ophthalmic  Reaction. — ^The  ophthalmic  test  was  made  615 
times;  in  most  instances  only  one  test  was  made  in  a  patient,  although  in  a 
few  children,  where  the  results  were  questionable,  the  test  was  repeated. 
The  ophthalmic  tests  were  all  made  with  tuberculin  obtained  from  the 
Rockefeller  Institute,  and  which  had  been  precipitated  with  65  per  cent, 
alcohol.  Before  using,  it  was  freshly  dissolved  in  a  sterile  saline  solution. 
For  the  first  half  of  these  tests  a  1  per  cent,  solution  was  used,  for  the  latter 
half,  a  0.5  per  cent.  Especial  care  was  taken  not  to  use  the  tuberculin  in 
an  eye  that  was  the  seat  of  any  disease.  As  a  further  precaution,  the  hands 
of  the  children  were  bound  during  the  first  twelve  hours,  to  prevent  any 
rubbing  of  the  eye. 

In  the  following  table  are  given  the  reactions  in  the  different  types  of 

551 


552 


SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 


cases.     In  the  group  marked  Probably  not  Tuberculosis  are  included  those 
in  which  no  evidence  of  tuberculosis  other  than  the  reaction  existed. 


RESULTS  IN  615  OPHTHALMIC  TESTS. 


Pathological  Condition. 

Positive   Re- 
actions. 

Negative  Re- 
actions. 

Doubtful  Re- 
actions. 

Positive  tuberculosis  (autopsy  or 
bacilli  in  sputum) 38 

Probable  tuberculosis   (evidence: 
other  tuberculin  reactions,  his- 
tory, or  physical  signs.) 21 

Probably  not  tuberculosis, 555 

Positively  not   tuberculosis    (au- 
topsy)        1 

25 

19 
2 

1 

10  (9  dying  or 
extremely 
sick  children). 

546 

3 

2 

7  (all  slight). 

Totals 615 

47 

556 

12 

The  clinical  course  which  the  reaction  follows  is  its  most  diagnostic 
feature,  and  hence  rather  close  observation  of  a  patient  is  necessary  or  some 
of  the  milder  reactions  will  be  overlooked.  There  is  usually  congestion  of 
the  conjunctiva,  with  some  swelling  and  an  increased  secretion  of  mucus, 
which  is  frequently  very  abundant,  so  that  the  lids  are  adherent.  Pus- 
cells  are  seldom  present,  and  repeated  cultures  revealed  no  microorganisms. 
The  symptoms  generally  appear  in  from  six  to  eight  hours  after  the  tuber- 
culin in  used,  and  reach  their  height  in  the  first  twenty-four  hours,  fading 
gradually.  The  usual  duration  of  symptoms  is  from  one  to  three  days. 
In  about  12  per  cent,  of  the  cases  the  reaction  lasted  somewhat  longer  than 
three  days;  in  one  case  it  lasted  ten  days,  but  in  no  case  was  the  test  followed 
by  any  unpleasant  results.  By  comparison  with  the  opposite  eye,  the 
existence  of  a  reaction  may  in  most  cases  be  confirmed.  There  were,  how- 
ever, a  few  cases  in  which  the  symptoms  were  so  slight  that  the  results  must 
be  classed  as  doubtful. 

I  am  aware  that  serious  results  with  the  ophthalmic  test  have  occasionally 
been  reported.  The  precautionary  measures  taken  in  this  group  of  cases 
are,  I  believe,  of  considerable  importance,  and  are  largely  responsible  for 
the  absence  of  unpleasant  results.  On  account  of  the  kind  of  observation 
necessary  and  the  possible  dangers  connected  with  the  eye  test,  it  is  not 
wise  to  employ  it  indiscriminately,  for  example,  among  the  out-patients 
of  a  hospital. 

The  statement  has  been  repeatedly  made  that  young  infants  do  not 
respond  to  the  eye  test.  This  was  not  borne  out  by  our  experience.  Of 
this  series  of  cases,  positive  reactions  were  obtained  in  14  patients  under 


ONE   THOUSAND   TESTS   IN   YOUNG    CHILDREN. — HOLT. 


553 


one  year  old,  6  of  whom  were  under  six  months  and  1  only  two  months  old. 
So  far  as  we  could  see,  the  character  of  the  reaction  and  the  frequency  with 
which  it  occurred  were  not  affected  by  the  age  of  the  patient  nor  by  the 
extent  or  activity  of  the  pathological  process,  but  only  by  the  susceptibility 
of  the  patient.  In  no  cases  were  positive  reactions  obtained  in  djdng  chil- 
dren or  in  those  suffering  from  extreme  prostration.  In  this  respect  it 
corresponded  with  the  other  tests. 

The  Skin  Reaction. — ^The  skin  test  of  von  Pirquet  was  employed  217 
times.  It  was  made  with  crude  tuberculin  obtained  from  the  laboratory 
of  the  New  York  Health  Department,  which  was  simply  diluted  with  sterile 
water  to  a  25  per  cent,  strength.  Tkree  linear  scratches  were  made,  usually 
upon  the  extensor  surface  of  the  forearm,  and  the  tuberculin  was  rubbed 
into  the  middle  one.  The  skin  was  allowed  to  dry  and  then  covered  for  a 
few  hours  with  a  piece  of  sterile  gauze.  The  reaction  usually  began  in 
from  six  to  twelve  hours,  and  only  twice  later  than  twenty-four  hours. 
It  reached  its  height  in  most  cases  in  from  twenty-four  to  thirty-six  hours. 
The  duration  varied  considerably.  It  was  generally  from  two  to  four  days, 
but  not  infrequently  lasted  a  week  or  longer,  fading  slowly.  Although  it 
varied  considerably  in  intensity,  it  was  generally  perfectly  definite,  and  in 
no  instance  was  the  result  considered  doubtful. 

A  summary  of  the  reactions  obtained  in  the  different  pathological 
conditions  is  given  in  the  following  table.  As  in  the  table  of  ophthalmic 
reactions,  Probably  not  Tuberculosis  signifies  no  other  evidence  of  tu- 
berculosis existed  than  the  reaction  to  the  test. 


RESULTS  IN  217  SKIN  TESTS  (VON  PIRQUET). 


Pathological  Condition. 

Positive  Reactions. 

Negative  Reactions. 

Positive  tuberculosis  (sputum,  autopsy  or 
operation) 22 

Probable  tuberculosis  (evidence:  other 
tests,  history  or  physical  signs) 20 

Probably  not  tuberculosis 172 

Positively  not  tuberculosis  (autopsy) 3 

12 

15 
6 

10  (9  dying  or  ex- 
tremely sick  chil- 
dren;   1  cured) 
5 
166 
3 

Totals 217 

33 

184 

The  reaction  in  general  corresponded  with  the  pathological  condition, 
the  exceptions  being  the  second  and  third  groups  of  cases,  in  which  we  had 
no  means  of  determining  definitely  as  to  the  reliabiUty  of  the  reaction. 

The  skin  test  posses.ses  the  great  advantages  of  ease  of  application,  of 
not  requiring  close  ol).servation,  and  of  freedom  from  unpleasant  or  serious 
consequences.     In  no  instance  was  any  untoward  effect  seen  to  follow  the 


554  SIXTH   INTERNATIONAL  CONGRESS   ON   TUBERCULOSIS. 

inoculation  or  any  excessive  reaction.  With  the  two  scarifications  for 
control  there  was  little  difficulty  in  recognizing  a  positive  reaction. 

The  Puncture  Reaction. — When  tuberculin  is  injected  to  secure  the 
fever  reaction  in  doses  ranging  from  y^  milligram  to  5  milligrams,  no  local 
reaction  is  observed  if  the  injections  are  made  deep  into  the  muscles.  If, 
however,  they  are  made  subcutaneously,  a  local  reaction  is  regularly  seen 
in  cases  in  wliich  a  positive  fever  reaction  occurred.  This  phenomenon, 
first  observed  by  Epstein,  and  afterward  by  Schick,  is  known  as  the  "stich- 
reaction."  In  38  cases  tuberculin  was  injected  subcutaneously  for  the 
purpose  of  obtaining  this  puncture  reaction.  The  usual  dose  employed  for 
this  purpose  was  y|^  milligram.  These  patients  were  all  submitted 
previously  or  subsequently  to  von  Pirquet's  skin  test.  The  skin  reaction 
corresponded  in  every  instance  with  the  puncture  reaction,  hence  it  seems 
unnecessary  to  tabulate  the  cases  separately.  In  the  dose  mentioned  the 
puncture  reaction  was  not  so  marked  as  when  a  larger  dose — ^  or  1  milli- 
gram— was  used.  The  conclusion  drawn  from  this  limited  experience  was 
that  the  puncture  test  possessed  no  advantages  over  the  scarification  test, 
and  that  it  was  somewhat  more  troublesome  of  application. 

Fever  Reaction  to  Tuberculin  Injections. — Tliis  is  quite  as  reliable 
in  young  children  as  in  older  patients.  The  fever  test  is  limited  in  its 
apphcation,  since  most  cases  of  active  tuberculosis  at  this  period  of  life 
are  accompanied  by  fever.  Furthermore,  young  children  have  slight  rises 
of  temperature  from  so  many  causes  that,  unless  the  reaction  is  decided 
and  typical  in  its  course,  the  result  may  be  doubtful.  I  have  not  considered 
a  reaction  definite  unless  the  temperature  has  reached  at  least  102°  F.  It 
is  necessary  that  the  temperature  be  taken  at  four-hour  intervals  before  the 
injection  is  given,  and  after  the  injection,  at  two-hour  intervals.  Accurate 
dosage  is  a  matter  of  much  importance.  Very  small  doses  are  unreliable, 
and  too  large  doses  may  be  fraught  with  some  risk.  After  considerable 
experimenting  I  have  settled  upon  the  dose  of  J  milligram  for  infants  under 
six  months,  and  of  1  milhgram  for  those  who  are  older. 

Injections  of  tuberculin  in  patients  suspected  to  be  tuberculous  were 
employed  130  times.  For  the  most  part,  the  injections  were  made  deeply 
into  the  muscles,  and  no  local  reactions  were  observed.  The  temperature 
usually  began  to  rise  in  from  six  to  twelve  hours,  reaching  its  maximum  in 
from  four  to  eight  hours.  The  average  maximum  reaction  was  103.3°  F., 
which  was  reached,  on  the  average,  in  thirteen  hours.  The  temperature 
remained  near  the  highest  point  for  from  six  to  eight  hours,  and  then  fell 
rather  rapidly  to  the  normal.  As  a  rule,  the  larger  the  dose  given,  the 
more  rapid  the  reaction  and  the  higher  the  temperature.  In  no  case  were 
any  serious  symptoms  observed  to  follow  the  injection,  although  in  several 
instances  high  temperatures  were  accompanied  by  discomfort,  restlessness, 


ONE   THOUSAND   TESTS   IN   YOUNG    CHILDREN. — HOLT. 


555 


and  other  symptoms  indicating  a  constitutional  disturbance  of  some  severity. 
In  no  instance  was  it  apparent  that  the  injection  had  resulted  in  the  Hghting 
up  of  a  latent  tuberculous  process.  In  a  few  instances  a  general  erythema 
was  noticed,  such  as  follows  the  injection  of  diphtheria  antitoxin. 

The  results  of  the  injections  in  the  various  pathological  conditions  are 
shown  in  the  following  table  : 

RESULTS  OF  130  TUBERCULIN  INJECTIONS. 


Pathological  Condition. 

Positive   Re- 
actions. 

Negative  Re- 
actions. 

Doubtful  Re- 
actions. 

Positive  tuberculosis  (sputum, 
autopsy,  operation,  or  C.  S. 
fluid) 28 

Probable  tuberculosis  (evidence: 
other  tests,  histoiy,  or  physical 
signs 21 

Probably  not  tuberculosis 80 

Positively  not  tuberculosis  (au- 
topsy)        1 

22 

18 
1 

1 

2   (in  one  pa- 
tient   appar- 
ently cured). 

3 

78 

4 

i 

Totals 130 

42 

83 

5 

On  the  whole,  the  results  obtained  by  the  different  tests  corresponded 
with  one  another  and  with  the  pathological  condition  as  determined  by  other 
means,  the  only  notable  exception  being  that  dying  children  or  those  who 
were  extremely  sick  did  not,  as  a  rule,  react  to  any  of  the  tests.  An  attempt 
has  been  made  to  compare  the  reliability  of  the  different  tests  by  grouping 
the  exceptional  reactions  observed  in  16  cases  in  the  next  table.  The  num- 
bers, however,  are  too  small  to  admit  of  any  very  definite  conclusions. 

It  will  be  seen  that  some  failures  and  some  unexplained  reactions  occurred 
with  all  the  tests.  The  results  with  any  test  cannot,  therefore,  be  regarded 
as  conclusive,  although  a  positive  reaction  creates  a  very  strong  probability 
that  tuberculosis  is  present.  This  is  increased  if  the  result  is  confirmed 
by  other  tests. 

So  far  as  reliability  is  concerned,  there  is  not  much  choice  between  the 
skin  and  the  eye  test.  The  skin  reaction  is,  I  think,  more  characteristic 
and  less  likely  to  be  doubtful  than  are  some  of  the  eye  reactions.  Some 
instances  of  doubt  must  occur  in  the  temperature  reactions  on  account  of 
the  liability  of  small  children  to  shght  rises  of  temperature  from  minor 
digestive  disturbances  or  other  causes. 

In  ease  of  application  there  is  a  decided  advantage  in  the  skin  test.  The 
scarification  is  a  trifling  matter.  The  patient  does  not  require  continuous 
observation  before  or  after,  and  the  reaction  lasts  for  a  considerable  time. 
The  ophthalmic  cases  need  closer  watching,  the  reaction  is  shorter,  and  may 


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558  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

be  overlooked.  It  cannot  well  be  used  in  ambulatory  patients.  The 
puncture  test  is  slightly  more  of  an  operation  and  may  be  objected  to.  The 
fever  reaction  is  admissible  only  when  the  child  can  be  kept  under  very  close 
observation. 

Objectionable  features  are  wanting  in  the  skin  test.  There  is  no  local 
discomfort,  no  general  reaction,  and  I  have  seen  no  complications.  With 
proper  precautions  I  believe  the  eye  test  to  be  quite  safe,  although  an 
intense  or  prolonged  reaction  sometimes  occurs  which  is  somewhat  alarming; 
besides,  in  pathological  conditions  of  the  eye,  diastrous  results  may  follow. 
Moreover,  the  eye  is  too  deUcate  and  important  an  organ  to  be  used  for  a 
test  when  any  other  organ  will  answer  quite  as  well.  For  general  use,  the 
skin  test  is  to  be  preferred. 

With  the  temperature  reaction  we  may  get,  accompanying  the  fever, 
constitutional  symptoms  that  are  quite  disagreeable.  There  exists  a  possi- 
bility that  a  latent  process  may  be  lighted  up.  Mistakes  in  dosage,  which 
have  been  made,  may  be  followed  by  serious  consequences.  These  risks 
are  added  objections  to  the  use  of  this  test.  It  is  certainly  an  advantage 
to  have  several  tests,  both  for  purposes  of  confirmation  and  to  use  one 
where  another  is  not  applicable.  For  all  tests  one  must  be  sure  as  to  the 
purity,  strength,  and  freshness  of  the  tuberculin  used. 

All  these  tests  have  been  too  recently  introduced  for  the  final  word  to  be 
spoken  regarding  them.  No  test  is  absolutely  conclusive,  as  is  the  demon- 
stration of  the  tubercle  bacillus  in  the  sputum,  cerebrospinal  fluid,  or  else- 
where, and  one  should  not  fall  into  the  error  of  depending  upon  the  local 
tests  to  the  neglect  of  other  means  of  diagnosis,  even  though  the  search  for 
the  tubercle  bacillus  involves  greater  labor.  In  general,  while  the  tests 
furnish  strong  probability  of  the  existence  of  a  tuberculous  lesion,  they  do 
not  enable  us  to  distinguish  between  a  latent  and  an  active  concUtion.  This 
may  at  times  be  confusing.  A  child  may  give  a  positive  skin  or  eye  reaction 
when  suffering  from  an  acute  pulmonary  disease  wliich,  by  its  course,  is  shown 
to  be  non-tuberculous,  although  grave  suspicion  of  acute  pulmonary  tubercu- 
losis may  have  existed  and  apparently  be  confirmed  by  the  tuberculin  tests. 
Much  needless  alarm  may,  therefore,  be  produced  by  a  positive  reaction, 
which  really  indicates  only  that  a  tuberculous  focus  exists  somewhere,  but 
does  not  prove  that  the  present  disease  from  which  the  child  is  suffering 
is  of  a  tuberculous  nature.  While  of  the  greatest  assistance  in  diagnosis, 
the  various  tests  are  always  to  be  taken  in  connection  with  the  general 
symptoms  and  the  physical  signs.  Taken  apart  from  them,  however,  they 
may  be  very  misleading. 


THE  FREQUENCY  OF  TUBERCULOSIS  IN  CHILDHOOD. 


By  C.  von  Pirquet, 

Vienna. 


During  the  last  year  and  a  half  I  have  made  a  cutaneous  test  on  all  the 
children  who  were  admitted  to  the  children's  cUnic  of  Professor  Escherich 
in  Vienna.  Nearly  half  of  these  children  were  repeatedly  examined,  and, 
in  very  many  instances,  the  results  were  controlled  by  subcutaneous  injec- 
tions of  tuberculin — made  by  Dr.  Hamburger.  Two  hundred  cases  were 
examined  post  mortem. 

In  the  first  year  the  reaction  occurs  in  but  5  per  cent,  of  the  cases,  rapidly 
increases  in  the  following  years,  and  reaches  a  percentage  of  80  in  the  tenth 
year.  This  high  percentage  cannot  be  considered  as  the  figure  for  all  chil- 
dren, because  many  cases  are  admitted  into  the  hospitals  on  account  of 
tuberculosis.  In  the  first  year  of  life  nearly  all  reacting  cases  present 
clinical  symptoms  of  the  disease.  In  the  succeeding  year  the  number  of 
positive  reactions  far  exceeds  the  number  of  negatives.  This  proves  that 
not  all  infected  cases  present  clinical  symptoms.  In  other  words,  that 
latent  tuberculosis  becomes  more  frequent  in  succeeding  years. 

This  increase  of  latent  tuberculosis  is  more  clearly  shown  in  another 
study.  The  children  were  chiefly  those  who  came  to  the  hospital  for  some 
acute  infection,  and  the  healthy  babies  who  are  brought  for  observation, 
and  in  order  that  the  mothers  may  be  taught  how  to  care  for  them.  This 
group  should  give  some  idea  as  to  the  average  incidence  of  latent  tuberculosis 
among  the  healthy  children  of  Vienna.  In  the  first  two  years  no  reactions 
appear.  This  shows  that  during  that  time  an  infection  with  tuberculosis 
practically  does  not  occur  without  the  existence  of  some  clinical  phenomena, 
such  as  bronchitis  or  anemia.  On  the  other  hand,  the  increase  in  the  number 
of  reacting  children  in  the  following  years  is  nearly  as  high  as  in  the  first 
group,  and  reaches  70  per  cent,  in  the  tenth  year. 

In  cases  presenting  clinical  evidence  of  tuberculosis  the  reaction  is  posi- 
tive in  almost  all  cases  after  twenty-four  hours,  whereas  in  latent  tubercu- 
losis, especially  in  older  children,  we  see  about  half  of  the  cases  react  only 
after  some  days  (this  I  have  termed  a  "torpid  reaction");  and  some  react 
only  to  a  second  test  ("secondary  reaction").     Some  cases  in  which  the 

659 


560  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

cutaneous  test  was  negative  afterward  reacted  to  the  hypodermic  injection 
of  tuberculin.  These  three  lands  of  reactions  have  tliis  in  common — that 
a  slight  reactivity  against  tuberculin  exists,  which  is  too  weak  to  be  evidenced 
immediately,  but  which  is  aroused  after  the  first  application. 

What  does  this  form  of  reaction  mean?  One  can  say  that  it  generally 
means  a  slight  and  old  tuberculous  infection  which  is  in  the  process  of  healing. 
Up  to  the  present  time  I  have  not  had  a  sufficient  number  of  post-mortem 
examinations  to  prove  this  point  absolutely.  But  the  following  reasons 
speak  for  the  validity  of  this  view:  First,  the  autopsies  in  which  secondary 
or  torpid  reactions  w^ere  found  to  have  been  produced  by  slight  and  old 
tubercles;  second,  fresh  and  clinically  manifest  tuberculosis  does  not  show 
this  form  of  reaction;  third,  the  increase  of  these  secondary  reactions  from 
year  to  year  corresponds  in  its  percentage  to  that  established  by  Dr.  Ham- 
burger for  the  frequency  of  healed  tubercles  found  at  autopsy  in  children 
who  died  from  other  causes;  and  fourth,  we  have  a  similar  delay  in  the 
development  of  the  local  phenomena  in  revaccination  with  cow-pox  in  cases 
in  wliich  a  long  time  has  elapsed  after  the  previous  vaccination. 

I  conceive  that  the  reactivity  against  tuberculin  appears  some  weeks 
after  the  infection  has  occurred,  and  then  increases  in  degree,  after  some 
months,  rising  to  a  considerable  height.  If  the  tuberculosis  is  overcome  by 
the  individual,  and  is  healed,  the  reactivity  slowly  decreases  in  the  follow- 
ing years  below  the  level  of  cutaneous  activity.  We  know,  from  the  studies 
of  various  antibodies,  that  in  an  organism  wliich  has  once  formed  antibodies 
and  has  lost  them,  a  slight  reinfection  or  a  second  injection  with  the  same 
poison  quickly  stimulates  a  new  and  strong  formation  of  antibodies.  In  a 
similar  fasMon,  if  a  person  with  a  latent  or  healed  tuberculosis  is  again  in- 
fected with  tubercle  bacilli  or  if  he  absorbs  even  a  minimal  amount  of  tuber- 
culous poison  (by  means,  for  instance,  of  a  cutaneous  tuberculin  test)  he 
again  forms  antibodies,  and  shows  some  days  or  a  week  later  a  high  reactiv- 
ity. A  high  reactivity  does  not  prove  the  existence  of  an  active  tuberculous 
process,  in  the  sense  that  the  tuberculosis  is  progressive.  It  only  proves 
that  the  organism  has  recently  come  in  contact  with  tubercle  bacilli  or  their 
poisons. 

Therefore,  we  can  conclude  that  in  older  children  the  tuberculin  reactiv- 
ity may  be  present  in  apparently  perfect  health.  This  coincides  with  the 
facts  established  by  Naegeli,  F.  Hamburger  and  others,  based  on  autopsies 
made  in  children  of  various  ages. 

The  percentage  of  infected  (reacting)  children  is  a  particularly  high  one 
in  my  studies.  In  other  cities  it  will  hardly  be  as  high  because  tuberculosis 
is  notoriously  prevalent  in  Vienna.  Furthermore,  all  of  my  patients  be- 
longed to  the  poorer  classes.  My  statistics,  therefore,  lose  in  some  degree 
their  general  value.     Our  children  are  infected  at  a  much  earlier  age  on 


THE   FREQUENCY    OF   TUBERCULOSIS   IN    CHILDHOOD. — PIRQUET.         561 

account  of  the  prevalence  of  tuberculosis  among  their  parents.  It  is  neces- 
sary to  make  similar  studies  in  every  city  in  order  to  ascertain  the  frequency 
of  tuberculosis  in  general. 

I  should,  therefore,  like  to  suggest  a  definite  method  for  international 
use.     The  method  is  as  follows: 

All  children  should  be  submitted  to  the  cutaneous  test.  The  following 
day  they  are  inspected.  Those  showing  a  positive  reaction  are  noted  as 
belonging  in  the  group  of  early  reactions.  A  week  later  those  showing  no 
reaction  are  again  tested  and  inspected  a  day  later.  If  they  then  react,  they 
are  grouped  in  the  class  of  secondary  reactions.  Those  who  have  not  re- 
acted on  either  occasion  can  be  considered  as  belonging  to  the  non-reacting 
class.  This  method  of  testing  requires  about  one  hour  for  a  hundred  chil- 
dren, and  only  half  an  hour  is  consumed  in  the  inspecting  process.  Med- 
ical school  officers  could  easily  accomplish  this  at  the  opening  of  the  schools 
in  autumn.  One  forenoon  would  be  sufficient  for  a  school  of  from  four 
hundred  to  six  hundred  children.  As  the  test  is  absolutely  harmless,  there 
can  be  no  objection  to  carrying  out  such  valuable  investigations. 

The  classification  given  above  is  not  perfect,  inasmuch  as  the  class  of 
non-reacting  children  will  contain  some  individuals  who,  at  a  further  repeti- 
tion of  the  test,  would  react  and  therefore  would  have  to  be  transferred  from 
the  third  to  the  second  class.  Three  or  more  trials  for  three  or  more  consecu- 
tive weeks  can  be  easily  performed  in  hospitals.  One  can  also  employ  the 
more  rapid  method  of  Dr.  Hamburger,  which  consists  in  injecting  one  milli- 
gram of  tuberculin  subcutaneously  into  the  non-reacting  children  and 
examining  them  on  the  following  day  for  a  local  subcutaneous  reaction  (so- 
called  Stichreaction).  This  method  is,  on  the  whole,  quicker  and  more 
exact,  but  is  not  as  feasible  for  use  on  a  large  scale  as,  for  example,  in  the 
schools.  For  practical  and  especially  for  statistical  purposes  the  repeated 
cutaneous  test  may  be  considered  sufiicient. 

The  next  idea  in  reference  to  my  proposals  of  an  international  statistical 
study  is  to  ascertain  at  what  age  children  generally  acquire  the  tuberculous 
affection.  We  would  then  be  able  to  say  at  what  age  they  are  most  sus- 
ceptible. I  hope  that,  by  repeated  annual  tests  and  at  the  same  time  de- 
termining the  clinical  symptoms  which  arise  between  the  last  negative  and 
the  first  positive  reaction,  we  may  be  able  to  establish  the  onset  of  the  disease. 
In  this  way  we  will  be  in  a  position  to  institute  the  proper  hygienic  measures 
for  the  prevention  of  tuberculous  infection  in  childhood,  especially  at  the 
period  of  greatest  danger. 


562 


SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 


Age  Last  Birthday. 


1  year. 

2  years 

3  years 

4  years 

5  years 

6  years 

7  years 

8  years 

9  years 

10  years 

11  years 

12  years 

13  years 

14  years 

15  years 

16  years 

17  years 

18  years 

19  years 

20  years 


Number  Reported  On. 


33 


37 


43 


Total. 


113 


3 
3 

4 

6 

11 

10 

10 

9 

5 

8 

11 

6 

8 

6 

2 

.5 

1 

4 
1 


Number  of 

Living-rooms 

Number  Reported  On. 

Total. 

32 

9 

16 

57 

One 

6 

17 

5 

4 

5 
2 
2 

1 

5 

8 
2 

1 

Two 

6 

Three 

27 

Four 

15 

Five 

8 

Six 

0 

Seven 

0 

Number 

OF  Children 

Living. 

Number  Reported  On. 

Total. 

32 

13 

15 

60 

One 

4 
3 
10 
4 
6 
5 

3 

5 
5 

1 
3 
6 

5 

5 

Two 

9 

Three 

16 

Four 

9 

Five 

11 

Six 

10 

Seven 

0 

Number  of  Children   Dead. 

Number  Reported  On. 

Total. 

32 

13 

15 

60 

One 

3 

8 
2 

2 

5 
12 

1 
4 

8 

5 

i 

2 

i 

6 

9 

Two 

12 

Three 

3 

Four 

2 

Five 

2 

Six 

1 

Seven 

5 

None 

26 

THE   FREQUENCY   OF   TUBERCULOSIS   IN   CHILDHOOD. — PIRQUET. 


563 


Number   o 

F   Adults   in    Family. 

NuMBEB  Repobted  On. 

Total. 

17 

8 

5 

30 

One 

Two 

3 
13 

i 

1 
7 

3 

2 

4 
23 

Three 

Pour 

2 
1 

Quality   of   Food. 

Number   Reported   On. 

Total. 

33 

12 

14 

59 

Good 

15 

18 

5 

7 

7 
7 

27 

Bad 

32 

Service    and    Cooking. 

Number  Reported  On 

Total. 

33 

12 

14 

59 

Good 

Bad 

21 
12 

7 
5 

7 

7 

35 

24 

Member  of  Family  Sick. 

Number  Families  Reported  On. 

Total. 

16 

21 

20 

56 

Father  and  Mother 

3 

10 

2 

1 

i 

is 

6 

(Adopted 
Child) 

U 
3 

i 

1 

i 

1 

(2  in  1 
Family) 

3 

Father 

Mother 

38 
11 

Aunt 

1 

Uncle 

1 

Grandfather 

1 

Grandmother 

Brother 

0 
1 

Sister 

1 

Uncle  and  Aunt 

1 

Physical  Condition 

of  Patient. 

Number  Reported  On. 

Total 

19 

8 

9 

36 

Dead 

1 

3 

15 

3 
3 
2 

1 
3 
5 

5 

In  Bed 

9 

At  Work 

22 

Expectoration. 

Number  Reported  On. 

Total. 

15 

6 

6 

27 

Profuse 

10 

5 

4 

2 

3 
3 

17 

Scant 

10 

564 


SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 


Nutrition. 

Good 

Bad 


Number  Reported   On. 


33 


22 
11 


12 


11 


Height. 

Number   Reported   On. 

Total. 

•• 

Above  Standard  (Amer.) 

Normal 

Below  Standard 

We!1Ght  (American.) 

Number  Reported  On. 

Total. 

Above  Standard 

Normal   

Below  Standard 

Total. 


56 


36 
20 


Glands. 

Number  Reportfd  On. 

Total. 

33 

26 

24 

83 

Enlarged  Anterior  Cervical  Glands .... 

28 

20 

18 

66 

Posture. 

Number  Reported  On. 

Total. 

33 

26 

25 

84 

Good 

20 
13 

16 
10 

19 
6 

55 

Bad 

29 

Conformation  of  Chest. 

Number   Reported   On. 

Total. 

33 

26 

24 

83 

Good 

24 
9 

17 
9 

18 
6 

59 

Bad 

24 

Conformation    of    Ribs. 

Number   Reported   On. 

Total. 

33 

26 

24 

83 

Good 

25 

8 

18 

8 

18 
6 

61 

Bad 

22 

THE   FREQUENCY   OF  TUBERCULOSIS   IN   CHILDHOOD. — PIRQUET.         565 


Teeth  (Decayed,  premature  loss, 
deformed  arches). 


Good. 
Bad.. 


Number  Reported  On. 


32 


3 
29 


13 


3 
10 


Position  of  Scapuk*:. 

Number  Reported  On. 

Total. 

33 

26 

25 

84 

Good 

22 
11 

17 
9 

19 
6 

58 

Bad 

26 

Total, 


54 


11 
43 


Oral  Hygiene  (Including  daily  toilet  of 
mouth — condition  of  gums). 

Number  Reported  On. 

Total. 

32 

9 

13 

54 

Good 

1 
31 

4 
5 

1 
12 

6 

Bad 

48 

Abnormal  Pulmonary  Condition. 

Number  Reported  On. 

Total. 

33 

23                     35 

91 

3 

1                     10 

14 

Tonsils. 


Number  Hypertrophied — including 
any  tonsil  with  enlarged  follicles 
protruding  or  submerged 


Number  Reported  On. 


33 


26 


31 


25 


37 


32 


83 


Adenoids. 

Number  Reported  On. 

Total. 

33 

31 

37 

101 

Number  Present 

32 

27 

37 

96 

Defective  Nasal  Breathinq. 

Number  Reported  On. 

Total. 

33 

29 

35 

97 

Number  Obstructed 

33 

25 

35 

93 

566 


SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 


Number  of  Calmette  Tests  Applied. 


Number  Positive , 


Number  Reported  On. 


30 


16 


(Degrees  of  reaction  stated  in 
reports  on  each  individual.) 


Total. 


43 


21 


Operations  Performed. 

Number  Reported  On. 

Total. 

33 

31 

37 

101 

Includes     tonsillotomy,      adenoidec- 
tomy,  turbinectomy 

5 

5 

3 

13 

Frequence  de  la  Tuberculose  chez  les  Enfants. — (von  Pirquet.) 

Comme  r^sultat  de  1400  examens  avec  I'^preuve  cutan^e  a  la  tubercu- 
line  a  la  clinique  de  Escherich  on  a  pr^par^  une  table  qui  montre  que  I'in- 
fection  par  la  tuberculose  augmente  d'annee  en  annee,  Ces  r(5sultats  ont 
et4  compares  avec  les  statistiques  compilees  des  autopsies  pratiqu6es  sur 
les  enfants. 

L'auteur  discute  la  signification  des  differentes  sortes  de  reactions  qui 
apparaissent  dans  les  premieres  ann^es  et  dans  les  annees  plus  avancees  de 
I'enfance. 

Je  propose  de  compiler  des  statistiques  Internationales  qui  devront 
dtre  pr^par^es  de  la  maniere  suivante: 

Les  enfants  de  tous  ages,  par  exemple  les  enfants  des  Kindergartens  et 
des  ecoles,  devront  etre  soumis  k  I'epreuve  cutan6e  le  premier  jour;  le  jour 
suivant  tous  devraient  etre  inspectes.  Ceux  qui  montrent  une  reaction 
devraient  etre  classes  comme  appartenant  a  la  clas.se  des  'reactions  pre- 
coces/  ce  qui  signifie  pratiquement  qu'ils  ont  eu  I'infection  recemment. 
Une  semaine  plus  tard  il  faudrait  soumettre  de  nouveau  a  I'epreuve  les 
enfants  qui  n'ont  montre  aucune  reaction  a  la  premiere  epreuve.  Une 
grande  proportion  des  enfants  plus  dges  reagiront  maintenant:  ils  appar- 
tiennent  k  la  classe  des  'reaction  secondaire,'  ce  qui  signifie  g^neralement 
qu'ils  ont  eu  I'infection  dans  les  annees  pr^cedentes.  Les  enfants  qui 
n'ont  r6agi  dans  aucune  des  deux  occasions  precitees  appartiennent  a  la 
troisieme  classe,  que  Ton  peut  consid^rer  comme  comprenant  ceux  qui 
sont  pratiquement  indemnes  de  la  tuberculose. 

Pour  obtenir  une  certitude  de  I'indemnite  de  cette  troisieme  classe,  on 


THE    FREQUENCY   OF    TUBERCULOSIS    IN    CHILDHOOD. — PIRQUET.         567 

peut  iiijecter,  le  jour  suivant,  les  enfants  qui  ne  reagissent  pas,  avec  1  mg. 
de  tuberculine,  suivant  la  proposition  de  F.  Hamburger,  et  inspecter  ces 
enfants  le  jour  suivant  pour  observer  la  reaction  sous-cutanee  locale.  Cette 
epreuve  evidemment  ne  serait  possible  que  dans  les  hopitaux,  tandis  que 
dans  les  ecoles  il  faut  se  contenter  des  epreuves  cutanees,  qui  peuvent  se 
faire  sans  inconvenient  pour  les  enfants. 

De  cette  maniere  on  pourrait  noter  dans  les  differentes  villes  la  pro- 
portion d'infection  pour  cent  et  les  ages  auxquels  cette  infection  survient 
et  on  pourrait  par  consequent  tirer  des  conclusions  pour  I'hygiene. 


Die  Haufigkeit  der  Tuberkulose  im  Kindesalter. — (von  Pirquet.) 

Als  das  Resultat  von  1400  Priifungen  mit  der  kutanen  Tuberkulin- 
probe  in  Escherich's  Klinik  wurde  eine  Tabelle  bereitet,  welche  die  Vermeh- 
rung  der  Infektion  der  Tuberkulose  von  Jahr  zu  Jahr  zeigt.  Diese  Resultate 
wurden  mit  der  Statistik  verglichen,  die  von  den  Sektionsberichten  der 
Kinder  gemacht  sind. 

Die  Bedeutung  der  verschiedenen  Arten  von  Reaktionen,  welche  im 
friihen  und  spaten  Kindesalter  erscheinen,  wird  erortert.  Ich  schlage 
vor,  dass  eine  Internationale  Statistik  in  der  folgenden  Weise  gemacht  wird: 

Dass  Kinder  in  alien  Altersstufen  vom  Kindergarten  bis  zur  allgemeinen 
Schule  mit  der  kutanen  Probe  am  ersten  Tage  geprlift  werden;  am  folgen- 
den Tage  sollten  sie  alle  untersucht  werden.  Diejenigen,  welche  eine  Re- 
aktion  zeigen,  sollte  man  als  zur  Klasse  "  Friihreaktion "  bezeichnen,  was 
eigentlich  eine  neuliche  Infektion  bedeutet.  Eine  Woche  spater  werden 
diejenigen  Kinder,  welche  auf  den  ersten  Versuch  nicht  reagierten,  wieder 
der  Probe  unterworfen.  Ein  grosser  Prozentsatz  von  alteren  Kindern 
wird  nun  reagieren,  und  sie  gehoren  zu  der  Klasse  "  Secundarreaktion " 
was  gewohnlich  eine  Infektion  in  friiheren  Jahren  bedeutet.  Diejenigen 
Kinder,  die  auf  keine  der  beiden  Priifungen  reagiert  haben,  gehoren  zur 
dritten  Klasse,  welche  als  tatsachlich  frei  von  Tuberkulose  betrachtet 
werden  kann. 

Um  Gewissheit  auf  Bezug  auf  die  dritte  Klasse  zu  erlangen,  konnte  man 
den  nichtreagierenden  Kindern  am  folgenden  Tage  ein  Milligramm  Tuber- 
culin nach  dem  Vorschlage  von  F.  Hamburger  einspritzen,  und  am  nachsten 
Tage  sollte  man  sie  untersuchen  in  Bezug  auf  die  lokale  subkutane  Reaktion. 
Diese  Priifung  natiirlich  ist  nur  in  einem  Spitale  moglich;  wahrend  man  in 
den  Schulen  sich  mit  den  kutanen  Priifungen  zufrieden  geben  muss,  die  ohne 
alle  Unbequemlichkeit  fiir  die  Kinder  gemacht  werden  kann. 

In  dieser  Weise  konnte  man  Notiz  nehmen  in  den  verschiedenen  Stadten 


568  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

von  dem  Prozentsatz  der  Infektion  und  von  den  Alter,  in  welchem  solche 
Infektionen  vorkommen,  und  man  konnte  fiir  die  Hygiene  Schlussfolgerun- 
gen  Ziehen. 


Dr.  Laislaw  Detre,  of  Budapest  made  an  address  on  the 

DIFFERENTIAL  CUTANEOUS  REACTION, 

and  demonstrated  his  diagnostic  method  by  presenting  a  group  of  children 
previously  inoculated  at  the  Children's  Hospital,  Washington. 

(See  Joint-Session  of  Sections  I  and  II.) 


CLINICAL   OBSERVATIONS    ON    THE    VON    PIRQUET 
REACTION  IN  CHILDREN. 

By  Henry  Heiman,  M.D., 

From  the  Children's  Service  of  Mt.  Sinai  Hospital,  New  York  City. 


In  the  determination  of  the  existence  of  systemic  infection  with  the 
tubercle  bacillus  during  the  periods  of  infancy  and  childhood,  we  are  often 
deprived  of  the  two  most  important  diagnostic  aids  in  this  field  of  medicine, 
namely,  the  bacteriological  examination  of  the  sputum  and  the  subcutaneous 
injection  of  tuberculin.  The  absence  of  expectoration  in  childhood  deprives 
us  of  the  former,  whereas  the  instability  of  the  body  temperature  and  the 
not  infrequently  severe  constitutional  reaction  following  tuberculin  injection 
render  the  latter  method  unreliable  and  unsafe. 

The  recent  announcement,  by  von  Pirquet,  of  a  diagnostic  reaction 
based  on  the  most  advanced  studies  in  immunity  and  anaphylaxis,  which 
is  particularly  applicable  to  the  period  of  infancy,  has,  therefore,  aroused 
universal  interest,  and  has  led  to  the  production  of  an  extensive  literature 
containing  the  records  of  many  series  of  clinical  and  pathological  obsei'va- 
tions. 

The  present  investigation  was  undertaken  in  the  Children's  Ward  of 
Mt.  Sinai  Hospital,  in  the  service  of  Dr.  Koplik.  The  technic  was  essen- 
tially that  described  by  von  Pirquet.  The  extensor  surface  of  the  arm  or 
forearm  was  the  usual  site  of  inoculation.  By  means  of  a  needle  or  a  specially 
devised  borer,  three  small  circular  abrasions,  from  |  to  an  inch  apart,  were 
made.  To  the  middle  one  a  drop  of  the  properly  diluted  tuberculin  solution 
was  applied,  while  to  the  other  two  (control  points)  a  drop  of  5  per  cent, 
solution  of  carboglycerin  was  similarly  applied.  In  the  cases  giving  a  posi- 
tive reaction  a  small  papule  surrounded  by  a  circular  areola  developed 
within  from  twelve  to  twenty-four  hours.  The  control  points  showed  a 
slight  inflammatory  reaction  of  only  a  few  hours'  duration.  The  papular 
stage  was  of  variable  duration.  In  none  of  the  cases  was  the  reaction  accom- 
panied by  severe  inflammatory  symptoms.  Swelling  of  the  axillary  lymph- 
nodes  was  not  noticed.  The  body  temperature  did  not  rise  subsequent 
to  the  application,  and  the  leukocyte  count  remained  unchanged. 

In  most  of  the  earlier  cases  a  25  per  cent,  solution  of  Koch's  old  tuberculin 
(obtained  from  the  Alexander  Laboratories  at  Marietta,  Pa.)  was  employed. 

569 


570  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

Recently,  in  order  to  determine  the  relative  delicacy  of  various  strengths 
of  tuberculin  solutions,  I  have  employed  a  10,  25,  and  100  per  cent,  solution 
of  tuberculin  simultaneously.  With  but  few  exceptions  the  10  per  cent, 
yielded  a  negative  result,  whereas  the  100  per  cent,  gave  the  same  results 
as  the  25  per  cent,  tuberculin  solution. 

TABLE  SHOWING  THE  RESULTS  OF  THE   VON  PIRQUET   TEST  IN  104 
CHILDREN  AGED  FROM  4  MONTHS  TO  13  YEARS. 

Character  of  RfcACTiON. 
CliDical  Diagnosia.  Positive.         Negative. 

Adenitis,  tuberculous 3 

Amblyopia,  congenital 1 

Arthritis,  chronic 1 

Arthritis,  syphilitic 2 

Autointoxication,  intestinal 1  2 

Bronchitis,  chronic 4 

Bronchopneumonia 1  4 

Chorea 1 

Empyema 4 

Endocarditis,  chronic 1  3 

Endocarditis,  ulcerative 1 

Enterocolitis 2 

Enteritis 1  8 

Gangrene,  pulmonary 1 

Glioma,  retinal 1 

Heart,  congenital 1 

Hydrocephalus,  internal 1 

Idiocy,  amaurotic  family 1  1 

Idiocy,  congenital 1 

Influenza 1 

Laryngitis,  acute 1 

Malaria,  tertia 2 

Marasmus 1 

Meningitis,  cerebrospinal 1 

Meningitis,  tuberculous 2  12 

Nephritis,  acute 1 

Pleurisy,  dry 1 

Pleurisy  with  effusion 4  2 

Pneumonia,  lobar 4 

Peritonitis,  tubercular 2  1 

Pseudoleukemia  (v.  Jaksch) 2 

PyehtLs 1 

Rachitis 1 

Sarcoma,  renal 1 

Syphilis,  congenital 2 

Tubercle,  solitary 1 

Tumor,  cerebellar 1  1 

Tuberculosis,  pulmonary 2 

Tuberculosis,  miliary 1 

Typhoid 1  8 

Total 26  78 

The  tuberculin  vaccination  was  performed  on  104  children,  the  ages 
ranging  from  four  months  to  thirteen  years;  26  children  showed  a  positive 
reaction  and  78  a  negative  one.  The  cases  giving  a  positive  reaction  included 
the  following:  3  cases  of  tuberculous  adenitis;  2  cases  of  tuberculous  menin- 
gitis; 2  cases  of  pulmonary  tuberculosis;  2  cases  of  tuberculous  peritonitis; 


VON   PIRQUET   REACTION   IN   CHILDREN. — HEIMAN,  571 

1  case  of  solitary  tubercle  of  the  brain;  1  case  of  miliary  tuberculosis;  4 
cases  of  pleurisy  with  effusion,  and  1  case  each  of  bronchopneumonia, 
glioma  of  the  retina,  amaurotic  family  idiocy,  rickets,  intestinal  intoxica- 
tion, sarcoma  of  the  kidney,  typhoid,  subacute  endocarditis,  acute  laryn- 
gitis, acute  endocarditis,  and  cerebellar  tumor. 

In  all  but  three  cases  the  diagnosis  was  based  on  clinical  observ^ations 
and  on  laboratory  investigations  alone.  One  case  of  miliary  tuberculosis 
and  one  of  amaurotic  family  idiocy  came  to  autopsy.  In  the  former, 
extensive  miliary  tuberculosis  of  the  lungs,  liver,  and  spleen  was  found, 
whereas  in  the  latter — the  case  of  amaurotic  family  idiocy — the  macro- 
scopical  appearance  of  the  organs  did  not  show  any  signs  of  tuberculosis. 
The  microscopical  changes  in  the  organs  are  still  under  investigation  in  the 
pathological  laboratory  of  the  hospital.  In  one  case  of  tuberculous  adenitis 
an  excised  portion  of  an  ulcer  of  the  mouth  showed  the  typical  microscopical 
appearances  of  tuberculosis. 

In  none  of  the  cases  of  pleurisy  with  effusion  could  the  tubercle  bacilli 
be  demonstrated  in  the  pleural  fluid.  In  one  case,  however,  a  cytological 
examination  gave  95  per  cent,  mononuclear  leukoc3d«s. 

One  rachitic  infant  gave  a  marked  cutaneous  reaction.  The  infant's 
mother  had  recently  died  of  pulmonary  tuberculosis,  but  there  was  no 
clinical  evidence  to  show  that  the  infant  itself  was  suffering  from  a  tuber- 
culous infection.  This  case  brings  up  the  interesting  question  of  the 
possibility  of  transmission  from  the  parents  of  the  specific  bodies  on  which 
the  cutaneous  reaction  is  supposedly  dependent. 

The  78  cases  which  gave  a  negative  reaction  included,  as  will  readily 
be  seen  from  the  table,  a  variety  of  morbid  conditions.  I  must  draw  special 
attention  to  the  group  of  tuberculous  meningitis — 12  out  of  14  were  negative. 
The  clinical  diagnosis  was  made  by  the  history,  clinical  course,  and  the 
character  of  the  fluid  obtained  by  lumbar  puncture.  In  4  of  these  cases 
tubercle  baciUi  were  found  in  the  cerebrospinal  fluid.  The  cutaneous 
application  was  performed  mthin  three  to  ten  days  of  the  time  of  death. 
In  one  case  a  100  per  cent.  tubercuUn  solution  was  applied  twice,  with 
negative  results.  This  patient  was  also  subsequently  injected  four  times 
with  0.001,  0.0015,  0.002,  and  0.0025  respectively,  with  negative  results. 
The  frequency  of  negative  reactions  in  this  class  of  cases,  where  the  systemic 
infection  is  either  very  intense  or  at  an  advanced  stage,  has  been  noted  by  a 
number  of  observers.  An  apparently  plausible  explanation  of  this  fact 
has  been  offered  by  von  Pirquet  and  others. 

As  the  cutaneous  reaction  is  supposed  to  be  dependent  on  the  presence 
of  specific  antibodies,  bacteriolysins,  or  ferments,  it  may  readily  be  con- 
ceived that  where  the  infection  is  very  severe  or  in  an  advanced  stage,  a 
diminished  production,  or  even  a  total  cessation  of  production,  of  these 


572  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

bodies  may  take  place.  This  conception  of  the  nature  of  the  reaction  gives 
the  basis  for  the  supposed  prognostic  value  of  the  test.  A  negative  reaction 
in  a  case  of  known  tuberculous  infection  is  thus  of  ominous  import. 

In  the  remaining  66  cases  there  was  no  reason  to  suspect  the  existence 
of  tuberculosis.  I  desire  to  call  special  attention  to  the  cases  of  typhoid 
fever  in  this  series  (9).  Several  European  observers  have  reported  the 
frequent  occurrence  of  a  positive  reaction  in  this  infectious  disease.  In 
only  one  of  our  tj^^hoid  patients  was  the  reaction  positive,  but  as  the  case 
did  not  come  to  autopsy,  the  existence  of  tuberculosis  could  not  be  positively 
excluded;  however,  clinically  no  evidence  of  tuberculosis  was  present. 

The  result  of  the  present  investigation  shows  the  limitations  of  tliis  test 
in  two  directions,  and  is  in  correspondence  with  the  results  of  other  observers 
in  this  field.  The  method  apparently  fails  us  in  the  advanced  cases  of 
tuberculosis ;  a  fact  which,  as  has  been  said  before,  may  prove  to  be  of  great 
prognostic  importance.  The  limitation  of  the  method  in  the  other  direc- 
tion, namely,  in  its  being  positive  in  apparently  non-tuberculous  conditions, 
is  a  much  more  serious  drawback.  Eleven  of  the  104  cases  must  be  placed 
in  tliis  category.  The  existence  of  latent  tuberculosis  in  these  cases  cannot, 
however,  be  excluded.  It  is  to  be  hoped  that,  perhaps,  by  the  proper 
dilution  of  the  tuberculin  or  some  other  modification  of  the  method  of 
application,  we  will  obtain  a  reaction  in  cases  of  active  tuberculosis  only, 
and  thus  greatly  enhance  the  diagnostic  value  of  this  test. 


Algunas  Observaciones  Clinicas  Sobre  la  ReaccJ6n  de  von  Pirquet  en 

los  Ninos. — (Heiman.) 

Cincuenta  y  siete  ninos  fueron  vaccinados  por  el  metodo  de  V.  Pirquet  en 
el  Hospital  Monte  Sinai,  en  el  servicio  de  los  ninos  del  Dr.  Koplik  y  del 
autor,  de  los  cuales  veinte  dieron  una  reacci6n  positiva  y  en  treinta  y  siete 
la  reaccion  fue  negativa. 

Entre  los  veinte  ninos,  en  los  cuales  la  reaccion  fue  positiva,  las  con- 
diciones  morbidas  fueron  las  siguientes:  Tuberculosis  de  las  glandulas 
linfaticas,  3  casos;  meningitis  tuberculosa,  2;  peritonitis  tuberculosa,  2; 
tuberculosis  del  cerebro,  1;  tuberculosis  pulmonar  (probable),  2;  pleuresla 
con  efusion,  4;  bronco-neumonia,  1;  glioma  de  la  retina  y  dactilitis  mul- 
tipUce,  1;  idiotismo  amaurotico  hereditario,  1;  raquitis,  1;  intoxicacion 
intestinal,  1;  y  sarcoma  del  rifion,  1. 

Los  treinta  y  seite  casos  negativos  incluyen  las  enfermedades  siguientes; 
AmbUopia  congenital,  1;  artritis  crdnica,  1;  artritis  sifilftica,  2;  auto- 
intoxicacion  intestinal,  1;  bronquitis  cronica,  3;  bronco-neumonfa,  3;  entero- 
colitis,   2;  empiema,    3;  gangrena   pulmonar,    1;  idiotismo    hereditario   y 


VON    PIRQUET   REACTION   IN    CHILDREN. — HEIMAN.  573 

amaurosis,  1;  idiotismo  congenital,  1;  marasmo,  1;  meningitis  tuberculosa, 
8;  nefritis  aguda,  1;  pleuresia  con  efusion,  1;  pleuresia  seca,  1;  neumonia 
lobular,  1;  seudo-leuquemia  (v.  Jaksch),  1;  pielitis,  1;  slfiles,  1;  tumor  del 
cerebelo,  1;  tifoidea,  1. 

El  autor  hace  especial  mencion  de  los  casos  de  meningitis  tuberculosa  en 
los  cuales  un  ochenta  por  ciento  (8  en  10),  dieron  una  reaccion  negativa. 
Probablemente  esto  es  debido  al  hecho  de  que  la  vaccinacion  fue  hecha 
durante  el  ultimo  periodo  de  la  enfermedad,  en  el  cual  la  ausencia  de  bac- 
teriolisinas  impidio  la  reaccion  positiva. 


Quelques  observations  cliniques  sur  la  reaction  de  v.  Pirquet   chez  les 

enfants. — (Heiman.) 

Cinquante-sept  enfants  ont  et6  vaccines,  d'apres  la  m6thode  de  v.  Pir- 
quet, a  I'hopital  Mt.  Sinai,  dans  le  service  des  maladies  des  enfants  de  Drs. 
Koplik  et  Heiman.     La  reaction  fut  positive  dans  20  cas  et  negative  dans  37. 

Les  20  enfants  qui  ont  montre  une  reaction  positive  etaient  atteints  des 
maladies  suivantes:  Adenite  tuberculeuse,  dans  3  cas;  meningite  tuber- 
culeuse,  2;  p^ritonite  tuberculeuse,  2;  tubercule  solitaire  du  cerveau,  1; 
tuberculose  pulmonaire  (probable),  2;  pleuresie  avec  effusion,  4;  broncho- 
pneumonie,  1;  gliome  de  la  ratine  et  dactylite  multiple  1;  idiotisme  amau- 
rotique  (familial),  1;  rachitisme,  1;  intoxication  intestinale,  1;  et  sarcome 
du  rein,  1. 

Les  37  cas  negatifs  pr^sentaient  les  affections  suivantes:  Amblyopic 
congenitale,  1;  arthrite  chronique,  1;  arthrite  syphilitique,  2;  auto-intoxi- 
cation intestinale,  1;  bronchite  chronique,  3;  broncho-pneumonie,  3; 
entero-colite,  2;  empyeme,  3;  gangrene  pulmonaire,  1;  idiotisme  amaurot- 
ique  (familial),  1;  idiotisme  congenital,  1;  marasme,  1;  meningite  tuber- 
culeuse, 8;  nephrite  aigue,  1;  pleuresie  avec  effusion,  1;  pleuresie  seche,  1; 
pneumonic  lobaire,  1;  pseudo-leucocyth^mie  (v.  Jaksch),  1;  pyelite,  1; 
syphiUs,  1;  tumeur  du  cerebellum,  1,  et  fievre  typhoide,  1. 

Nous  devons  attirer  I'attention  speciale  sur  les  cas  de  meningite  tuber- 
culeuse. 80%  (8  sur  10)  montrerent  une  reaction  negative,  ce  qui  est 
probablement  du  a  ce  que  la  vaccination  fut  faite  vers  la  fin  de  la  maladie, 
lorsque  I'absence  d'anti-corps  ou  de  bact^riolysines  ne  permettait  pas  de 
reaction  positive. 

Einige   klinische  Beobachtungen   bei  der  v.  Pirquet'schen  Reaction  bei 

Kindern. — (Heiman.) 

Siebenundfiinfzig  Kinder  waren  nach  der  v.  Pirquet'schen  Methode  im 
Mount  Sinai  Hospitale  in  Dr.  Koplik's  und  meiner  Kinderabteilung  geimpft 
worden :  20  Kinder  zeigten  eine  positive  und  20  eine  negative  Reaction. 


574  SIXTH  INTERNATIONAL  CONGRESS   ON  TUBERCULOSIS. 

Die  20  Kinder,  die  eine  positive  Reaction  ergaben,  litten  an  folgenden 
krankhaften  Zustanden:  Tuberkulose  Adenitis,  3  Falle;  tuberkulose  Menin- 
gitis, 2;  tuberkulose  Peritonitis,  2;  Solitartuberkel  des  Gehirns,  1;  Lun- 
gentuberkulose  (vielleicht),  2;  Pleuritis  mit  Effusion,  4;  Bronchopneu- 
monie,  1;  Gliom  der  Retina  und  multiple  Dactylitis,  1;  amaurotische 
Familienidiotie,  1;  Rachitis,  1;  intestinale  Intoxication,  1;  und  Sarkom 
der  Nieren,  1. 

Die  37  negativen  Falls  schlossen  die  folgenden  Krankheiten  in  sich: 
Congenitale  Amblyopie,  1;  chronische  Arthritis,  1;  syphilitische  Arthritis, 
2;  intestinale  Autointoxication,  1;  chronische  Bronchitis,  3;  Broncho- 
pneumonie,  3;  Enterocolitis,  2;  Empyem,  3;  Lungengangran,  1;  amauro- 
tische Familienidiotie,  1;  angeborene  Idiotie,  1;  Marasmus,  1;  tuberkulose 
Meningitis,  8;  acute  Nephritis,  1;  Pleuritis  mit  Effusion,  1;  trockene  Pleu- 
ritis, 1;  Lobarpneumonie,  1;  Pseudoleukamie  (v.  Jaksch),  1;  Pyelitis,  1; 
Syphilis,  1;  Gehirntumor,  1;  Typhus,  1. 

Besondere  Aufmerksamkeit  muss  den  Fallen  von  tuberkuloser  Menin- 
gitis zugewendet  werden.  Achtzig  Prozent  (acht  von  unseren  zehn)  gaben 
eine  negative  Reaction.  Dies  hangt  vielleicht  von  der  Thatsache  ab,  dass 
die  Impfung  wahrend  des  Endstadiums  der  Krankheit  vorgenommen  wurde, 
als  die  Abwesenheit  von  Antikorpern  oder  Bacteriolysinen  das  Vorkommen 
einer  positiven  Reaction  verhinderte. 


RECENT  TESTS  IN  THE  DIAGNOSIS  OF  TUBERCULOSIS 
IN  CHILDREN  AT  THE  NEW  YORK  POST-GRAD- 
UATE MEDICAL  SCHOOL  AND  HOSPITAL. 

By  Henry  Dwight  Chapin,  M.D., 

Professor  of  Diseases  of  Children,  New  York  Post-Graduate  Medical  School  and  Hospital, 

AND  T.  Homer  Coffin,  M.D., 

Instructor  in  Pathology,  New  York  Post-Graduate  Medical  School  and  Hospital. 


Since  the  conjunctival  test  was  recommended,  less  than  a  year  and  a 
half  ago,  it  is  estimated  that  about  10,000  tests  have  been  reported  by  various 
observers.  The  cutaneous  reactions  have  been  studied  and  reported  in  prob- 
ably half  this  number  of  cases.  These  tests  have  been  made  upon  patients 
of  varying  ages,  and  it  has  often  been  found  that  healthy  adults  show  positive 
results.  On  the  other  hand,  infants  and  childi'en  clinically  tuberculous 
react  in  a  significant  way,  while  healthy  patients  rarely  react  to  the  tests. 
Comparison  of  results  obtained  in  this  large  number  of  patients  is  difficult; 
the  strength  of  tuberculin  varies  widely;  the  condition  of  the  patient  at 
the  time  of  observation  is  frequently  not  stated,  and  the  stage  of  the  disease 
is  not  taken  into  account. 

In  125  cases,  adults  and  children,  clinically  tuberculous  and  non-tuber- 
culous, the  conjunctival  test  has  been  applied  in  this  hospital. 

Seventy  cases  were  studied  in  reference  to  the  conjunctival  reaction  in 
cases  plainly  tubercular.  The  patients  were  children  varying  in  age  from 
six  months  to  thirteen  years.  In  each  case  the  condition  was  closely  studied 
until  proved  to  be  clearly  tuberculous;  in  eleven  the  clinical  findings  were 
verified  at  autopsy,  and  the  others  by  microscopical  examinations  of  sputum, 
tissues,  spinal  fluid,  etc.,  wherever  obtainable.  Tliirty-seven  were  cases  of 
bone  tuberculosis,  demonstrated  by  operation.  In  all  the  conjunctival 
tests  a  uniform  preparation  of  tuberculin  was  used,  carefully  measured 
for  each  case.  The  preparation  was  a  0.5  per  cent,  solution  of  the  alcoholic 
extract  of  Koch's  old  tuberculin. 

The  observations  so  far  as  the  eye  test  is  concerned  were  undertaken 
with  several  objects  in  view:    (1)  Specificity  of  the  test;   some  observers 

575 


576  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

contend  that  the  test  is  of  no  great  value  in  diagnosis  as  it  occurs  in  non- 
tuberculous  as  well  as  in  tuberculous  individuals.  (2)  Does  the  activity 
or  extent  of  the  lesion  bear  any  relation  to  the  degree  of  reaction?  (3)  Is 
the  test  of  value  in  prognosis?  (4)  Is  the  conjunctival  reaction  free  from 
danger? 

1.  Specificity  of  the  Test. — In  our  series  all  the  cases  were  clearly  tuber- 
culous. The  majority  of  them  had  tubercular  bone  disease.  Some  had 
pulmonary  tuberculosis;  others  had  well-marked  suppurating  glands, 
removed  and  examined  microscopically;  tubercular  meningitis,  verified 
at  autopsy  and  by  examination  of  spinal  fluid;  tubercular  peritonitis. 
In  six  cases  of  young  cliildren  under  three  years  of  age,  who  showed  marked 
malnutrition  and  were  steadily  losing  ground,  the  conjunctival  test  was 
positive.  Clinically  there  was  nothing  in  these  cases  upon  which  to  make 
a  positive  diagnosis  of  tuberculosis,  but  at  necropsy  caseous  bronchial 
glands  were  found.  In  our  post  mortems  upon  children  we  have  been 
impressed  with  the  frequency  with  which  this  picture  is  seen.  Children  in 
large  cities,  living  in  poor  hygienic  surroundings,  may  lose  weight  rapidly 
and  present  the  general  evidences  of  progressive  malnutrition.  In  many 
of  them  the  condition  must  form  what  these  and  similar  cases  reveal  at 
autopsy.  It  is  fair  to  believe  that  cases  of  this  nature  have  been  re- 
ported by  various  observers  as  not  tuberculous,  but  the  conjunctival  test 
reacted  to  all  of  this  class  of  cases  that  were  proved  by  autopsy  to  be 
tubercular.  Thus  in  cases  reported  to  give  a  reaction  in  apparently 
non-tubercular  patients,  this  obscure  type  of  tuberculosis  may  have  been 
present. 

2.  The  Degree  of  Reaction;  (3)  Prognosis. — In  young  children  crying 
may  interfere  with  the  conjunctival  test,  since  the  tears  wash  out  the  tuber- 
culin. Various  degrees  of  reaction  have  been  recognized  from  the  earliest 
observations  upon  this  test.  Some  cases  responded  quickly  and  mildly, 
while  others  reacted  quickly  and  strongly  and  persisted  for  some  days. 
Other  reactions  were  latent,  not  appearing  for  several  hours  or  a  day  after 
the  use  of  tuberculin.  All  these  facts  must  now  be  interpreted  as  significant. 
From  our  observations  on  actual  tuberculosis,  we  coincide  with  Wolff- 
Eisner  and  others  that  a  promptly  appearing  severe  reaction  indicates  a 
favorable  prognosis;  a  delayed  mild  reaction  indicates  a  healed  or  latent 
lesion.  The  more  severe  the  reaction,  the  better  are  the  prospects  of  cure. 
A  quickly  appearing  mild  reaction  or  failure  to  react  suggests  an  unfavorable 
prognosis  and  a  severe  and  active  tuberculous  process.  Two  cases  may 
be  noted  which  illustrate  tliis  point.  One  was  an  advanced  case  of  pul- 
monary tuberculosis  which,  soon  after  admission,  developed  tubercular 
peritonitis.  The  ocular  test  failed  to  react  in  this  case.  The  second  was  a 
well-marked  case  of  tubercular  peritonitis.    The  child  showed  advanced 


RECENT  DIAGNOSTIC  TESTS  FOR  TUBERCULOSIS. — CHAPIN  AND  COFFIN.     577 

emaciation  and  at  the  autopsy  typical  tubercular  lesions  were  found  in  the 
peritoneum.     This  case  likewise  showed  no  reaction. 

Cases  of  tubercular  meningitis,  with  clinical  evidences  of  severe  infection, 
uniformly  showed  no  reaction ;  advanced  cases  of  bone  tuberculosis  likewise 
failed  to  react,  while  cases  of  tuberculous  glands  and  other  localized  tuber- 
cular processes  gave  a  positive  reaction. 

When  we  consider  Wolff-Eisner's  theory  of  the  tuberculin  reactions, 
these  cases  are  made  clearer  of  comprehension.  In  individuals  with  tuber- 
cular lesions  there  are  present  in  the  blood  bacteriolysins  to  the  tubercle 
bacillus.  AH  tuberculins  contain  at  least  fragments,  splinters  of  tubercle 
bacilli;  when  these  come  in  contact  with  a  patient's  bacteriolysins,  en- 
dotoxins are  set  free  from  these  fragments  and  cause  the  phenomena  of  the 
reaction. 

4.  Dangers  of  the  Conjunctival  Reaction. — It  is  claimed  by  some  that 
lesions  of  the  eye,  not  tubercular,  have  been  aggravated  by  the  use  of  the 
conjunctival  test  and  that  general  and  constitutional  symptoms  have  been 
produced  by  the  instillations.  In  our  experience  ordinary  mild  conjunctiv- 
itis is  not  a  contraindication.  In  children,  cases  have  been  reported  of 
phlyctenular  conjunctivitis  lighted  up  by  the  test.  This  is  considered  to 
be  almost  always  a  scrofulous  manifestation.  These  children  possess  a 
hypersusceptibihty  to  the  poisons  of  the  tubercle  bacillus,  and  only  weak 
solutions  should  be  used  if  the  test  is  employed  at  all. 

We  have  seen  no  injurious  effect  from  the  conjunctival  test  in  125  cases 
in  which  it  was  employed.  The  worst  effect  was  a  mild  conjunctivitis  lasting 
from  two  to  three  weeks.  It  is  only  fair  to  add,  however,  that  a  careful 
preliminary  examination  of  the  eyes  was  always  made  to  exclude  ocular 
lesions  before  employing  the  test. 

The  Cutaneous  Test. — Hamill,  Carpenter,  and  Cope  have  reported  the 
results  obtained  in  134  cases  in  children  carefully  controlled.  The  con- 
junctival, Pirquet,  and  Morro  ointment  tests  were  used;  all  the  patients 
were  under  eight  years  of  age.  The  conjunctival  test  was  sometimes  fol- 
lowed by  serious  inflammations  of  the  eye,  with  even  a  possible  subsequent 
loss  of  vision.  In  their  opinion  the  skin  and  ointment  test  were  better  than 
the  conjunctival.  The  ointment  test  offers  the  advantage  that  it  does  not 
furnish  a  portal  of  entry  for  secondary  infections  through  abraded  surfaces. 
They  consider  that  all  these  methods  are  of  less  value  than  was  hoped  for 
in  the  diagnosis  of  irregular  forms  of  tuberculosis,  that  a  negative  reaction 
is  of  more  value  than  a  positive  one,  and  that  the  type  of  the  reaction  bears 
no  relation  to  the  type  of  the  disease.  Our  observations  do  not  coincide 
with  the  latter  view. 

Comby,  in  a  paper  read  before  the  Soci6t4  M^dicale  des  Hopitaux  in 
May,  extolled  the  cutaneous  reaction  for  use  in  children  because  of  its  com- 

VOL.  II — 19 


578  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

plete  innocuousness,  and  ascribed  its  want  of  popularity  to  the  fact  that 
its  method  of  use  had  not  been  laid  down  definitely.  He  uses  a  1  per  cent, 
solution  of  tuberculin,  which  is  also  employed  for  the  ocular  reaction.  In- 
stead of  scarification,  which  is  painful  and  to  which  patients  object,  he 
makes  three  pricks  with  the  vaccine  lancet  in  the  deltoid  region.  On  the 
next  day  and  on  the  day  after,  he  observes  the  result.  If  there  is  no  reaction, 
only  traces  of  the  pricks  can  be  seen — three  small  black  spots  without 
surrounding  redness.  If  the  reaction  is  positive  after  twenty-four  hours, 
or  later,  there  is  more  or  less  intense  redness  around  the  pricks.  This  is 
followed  by  papules  which  last  from  eight  to  ten  days. 

Von  Pirquet,  on  account  of  the  frequency  with  which  apparently  healthy 
adults  react  to  the  cutaneous  test,  has  considered  its  field  of  usefulness 
hmited  largely  to  the  study  of  tuberculosis  in  children.  Wolff-Eisner 
considers  that  the  cutaneous  test  reveals  the  presence  of  latent  or  healed 
tuberculosis,  while  the  conjunctival  test  shows  the  presence  of  more  or  less 
active  lesions.  The  great  value  of  the  cutaneous  test  is  as  an  aid  to  progno- 
sis; the  conjunctival  test  is  a  more  valuable  diagnostic  procedure. 

In  our  experience  the  cutaneous  test  is  not  so  easily  used  in  children  on 
account  of  the  pain  produced  by  the  vaccination.  Ten  cases,  all  clinically 
tubercular,  were  tested  in  this  manner.  The  results  were  approximately 
those  obtained  with  the  conjunctival  test.  Since  the  conjunctival  test  is 
so  readily  employed  and  has  been  so  satisfactory,  we  prefer  it  to  the  former. 

The  Opsonic  Index. — A  series  of  12  cases  of  tubercular  disease  of  the  hip 
and  spine  were  carefully  observed  with  reference  to  the  opsonic  index  in 
the  wards  of  tMs  hospital.  The  patients  were  children  varying  from  three 
to  thirteen  years  of  age.  The  tuberculo-opsonic  index  has  been  shown  to 
be  below  normal  in  most  cases  of  localized  tuberculosis,  though  it  may 
fluctuate  if  the  tubercular  process  is  active,  and  there  is  autointoxication. 
In  150  cases  of  localized  tuberculosis  Bulloch  found  that  the  average  index 
was  0.75,  and  in  22  cases  of  tubercular  bone  and  joint  disease  Potter,  Dit- 
man,  and  Bradley  found  that  the  index  was  below  normal  in  14,  normal  in 
3  cases,  and  above  normal  in  5. 

In  our  observations  it  was  found  that  in  severe  tubercular  infections 
the  index  is  often  high  or  may  be  low,  according  as  the  resistance  of  the 
patient  is  good  or  very  poor.  By  the  use  of  small  doses  of  tuberculin  the 
index  can  be  made  to  rise,  and  the  condition  of  the  patient  improves  with 
this  rise.  This  was  noticed  in  9  cases.  In  those  cases,  however,  which 
have  discharging  sinuses  and  secondary  infections  with  other  organisms,  it 
was  not  possible  to  improve  the  patient's  condition  by  the  use  of  tuberculin 
alone.     From  these  observations  the  following  conclusions  may  be  drawn: 

1.  The  opsonic  index  varies  with  the  severity  of  the  disease  and  the 
patient's  resisting  power. 


RECENT  DIAGNOSTIC  TESTS  FOR  TUBERCULOSIS. — CHAPIN  AND  COFFIN.     579 


2.  The  technic  of  obtaining  the  index  is  so  difficult,  and  when  estimated 
by  several  careful  observers  on  the  same  patient,  may  vary  so  widely,  that 
it  is  of  little  practical  value  in  diagnosis. 

3.  The  index,  when  obtained  by  careful  technic,  may  be  of  value  in 
prognosis,  as  sho\\dng  the  resistance  of  the  patient  to  the  toxins  produced 
by  the  tubercle  bacillus 

CLINICALLY  TUBERCULAR  CASES  TESTED  WITH  TUBERCULIN  APPLIED 

TO  CONJUNCTIVA. 

Age. 

1.  Pott's  disease 3 

2.  Pott's  disease 7 

3.  Pott's  disease 13 

4.  Tuberculous  hip 3^ 

5.  Pott's  disease 3 

6.  Pott's  disease 5 

7.  Pott's  disease 13 

8.  Pott's  disease 3 

9.  Pott's  disease 4 

10.  Pott's  disejise 11 

11.  Tubercular  knee  sinus .  11 

12.  Hip  disease 7 

13.  Pott's  disease 15 

14.  Hip  disease 6 

15.  Tubercular  dactylitis  .  2J 

16.  Tubercular  elbow  .... 

17.  Pott's  with  abscess. .  .  3 

18.  Double  hip 4 

19.  Hip  disease 3 

20.  Pott's  cervical 3 

21.  Hip  disease 6 

22.  Hip  disease 7 

23    Tuberculous  ankle 2^ 

24.  Pott't  disease 3 

25.  Pott's  disease 9 

26.  Hip  disease 12 

27.  Pott's  disease 7 

28.  Pott's  disease 5 

29.  Tub.  glands  of  neck ...  2 

30.  Tub.  glands  of  neck ...  7 

31.  Tub.  abscess  neck  ...  .17  months. 

32.  Tub.        bronchopneu- 

monia    4i 

33.  Tub.  foot.. 6 

34.  Fracture  tibia,  tuber- 

culosis secondary ...  5 

35.  Tub.  meningitis 3 

36.  Tub.  sinus,  neck 5 

37.  Tub.  foot,  cold  abscess 

shoulder 22  months. 

38.  Tuberculous  ankle 3^ 

39.  Tub.  meningitis 6  months. 

40.  Tub.  caries  of  spine..  .  3 

41.  Tub.  shoulder 6 

42.  Tub.    Submaxillary 

gland 5 

43.  Tub.  otitis  media 4i 

44.  Enteritis,      marasmus 

tubercular  (?) 2  Negative. 


Reaction. 

Condition  on  Dischakge. 

Positive,  mild. 

Severe  infection. 

Positive,  mild. 

Severe  infection. 

Positive,  marked. 

Improved. 

Positive,  marked 

Improved. 

Positive,  mild. 

Improved. 

Positive,  mild. 

Improved. 

Positive,  marked. 

Severe  infection  improved. 

Positive. 

Improved. 

Test  doubtful. 

Severe  infection. 

Test  doubtful. 

Severe  infection. 

Positive,  severe. 

Severe  infection. 

Positive,  mild. 

Severe  infection. 

Positive,  severe. 

Improved. 

Positive,  mild. 

Slight  conj.  for  three  weeks, 

Positive,  marked. 

Mild  infection. 

Positive,  marked. 

Mild  infection. 

Positive,  marked. 

Improved. 

Negative. 

Died.     Severe  infection. 

Negative. 

Died. 

Positive,  mild. 

Severe  infection. 

Positive,  mild. 

Severe  infection. 

Positive,  marked. 

Mild  infection. 

Positive,  marked. 

Mild  infection. 

Positive,  marked. 

Mild  infection. 

Positive,  marked. 

Mild  infection. 

Positive,  marked. 

Mild  infection. 

Positive,  marked. 

Mild  infection. 

Positive,  marked. 

Mild  infection. 

Positive,  marked. 

Improved. 

Positive,  marked. 

Improved. 

Negative. 

Severe  infection. 

Negative. 

Died. 

Positive,  marked. 

Improved. 

Positive. 

Improved. 

Negative. 

Died. 

Positive,  mild. 

Improved. 

Positive. 

Died. 

Positive. 

Improved. 

Positive. 

Died  three  weeks  later. 

Negative 

Severe  infection. 

Positive. 

Unimproved. 

Positive. 

Improved. 

Negative. 

Died. 

Died. 


580 


SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 


Clinically  Tubercular  Cases  Tested  with  Tuberculin  Applied  to 
Conjunctiva. — {Continued.) 
Age.  Reaction.  Condition  on  Discharge. 

45.  Tuberculous  elbow  ...  5  Positive,  marked.     Improved. 

46.  Tub.  meningitis 2\  Negative.  Died. 

47.  Tub.  pulmonalis ...  Slight.  Died. 

48.  Tub.  pul.  and  perito- 

nitis    4  Negative.  Unimproved. 

49.  Tub.  sinus  hand  and 

face 5  Negative.  Died.     Severe  infection. 

50.  Tub.  dactylitis,  double 

mastoid 3  Positive,  mild.  Died. 

51.  Tub.  lung  and  Pott's  .  4  Positive,  mild.  Unimproved. 

52.  Tub.  pul.  and  enteritis  22  months.  Negative.  Died.     Severe  infection. 

53.  Tub.    peritonitis     (se- 

vere)    3^  Negative.  Unimproved. 

54.  Tub.  bronchitis 20  months.  Positive.  Improved. 

55.  Empyema,  tubercular  1 1  months.  Negative.  Improved. 

56.  Cystitis 6  Positive.  Improved. 

57.  Tub.  peritonitis 16  months.  Negative.  Improved. 

58.  Tub.  meningitis 2 J  Positive,  mild.  Died. 

59    Tub.  glands,  neck  ....  Positive,  marked.     Improved. 

60.  Mil.  tuberculosis 1  Negative.  Died. 

61.  Tub.  peritonitis 21  months.  Positive,  mild.  Died. 

62.  Tub.  hip 3^  Positive.  Improved, 

63.  Tub.  periton.  and  pul- 

monary  20  months.  Partial.  Died. 

64.  Adenitis,  tubercular  . .  3i  Negative.  Cured. 

65.  Tub.  glands,  neck  (sup- 

purating)   18  months.  Positive,  marked.     Improved 

66.  Malnutrition,  tubercu- 

lous at  autopsy 8  months.  Positive,  mild.  Died. 

67.  (Same) 5^  months.  Positive,  mild.  Died. 

68.  (Same) 1  Positive,  mild.  Died. 

69.  (Same) 6  months.  Positive,  mild.  Died. 

70.  (Same) 9J  months.  Positive  mild.  Died. 


AN  AID  TO  THE  DIAGNOSIS  OF  TUBERCULOSIS  IN  IN- 
FANCY  AND    CHILDHOOD    BY    MEANS    OF    THE 
CUTANEOUS     INOCULATION    OF    DILUTED 
TUBERCULIN    OR     PURE    TUBERCULIN 
(PIRQUET    METHOD). 

By  Louis  Fischer,  M.D., 

Attending  Physician  to  the  Willard  Parker  and  Riverside  Hospitals  of  New  York  City, 


The  diagnostic  value  of  the  cutaneous  inoculation  with  pure  or  diluted 
tuberculin  has  been  the  subject  of  controversy  for  some  time.  As  an  aid 
to  the  diagnosis  of  latent  tuberculosis  this  method,  so  simple  in  its  applica- 
tion, has  many  advantages. 

The  absorption  of  the  tuberculin  gives  a  local  reaction — a  papule — a 
slight  zone  of  inflammation  about  10  millimeters  in  width,  with  no  constitu- 
tional disturbance.  There  is  neither  fever  nor  evidence  of  general  distur- 
bance, and  no  glandular  swelling.  This  local  reaction  remains  for  several 
weeks  in  older  children,  and  for  from  five  to  ten  days  in  infants. 

The  diagnosis  of  tuberculosis  in  infancy  and  early  childhood  is  frequently 
obscure.  Following  the  acute  infectious  diseases,  notably  measles,  broncho- 
pneumonia, diphtheria,  and  pertussis,  a  series  of  pulmonary  symptoms  will 
be  noted  in  wliich  tuberculosis  may  or  may  not  exist.  Cachexia  associated 
with  sj^Dhilis  frequently  suggests  tuberculosis.  Any  aid  to  diagnosis  will 
be  welcomed  provided  it  does  not  subject  the  little  patient  to  an  additional 
risk  and  does  not  devitalize  the  already  weakened  system. 

In  many  cases  progressive  emaciation  and  symptoms  resembling  mar- 
asmus will  be  seen,  caused  by  dyspeptic  or  intestinal  indigestion.  In  ob- 
scure lesions  involving  the  lungs,  brain,  and  intestines,  especially  in  the 
early  manifestations,  the  diagnosis  is  very  often  shrouded  in  mystery.  In 
just  such  cases  we  need  all  the  assistance  possible  in  order  to  arrive  at  a 
positive  conclusion. 

The  ocular  reaction  (Calmette)  is  not  devoid  of  danger.  Although  it 
has  been  before  the  profession  for  but  one  year,  many  cases  are  recorded  in 
which  serious  eye  lesions  developed.  I  have  observed  marginal  ulceration 
of  the  cornea,  and  a  similar  observation  has  been  made  by  other  investiga- 
tors in  New  York.  Barbier,  in  Paris,  reports  a  series  of  ulcerations  of  the 
cornea  and  pannus  following  the  instillation  of  a  1  per  cent,  diluted  tuber- 

581 


582  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

culin  solution.  Renom  also  reports  three  complications  in  a  series  of  28 
trials  in  the  eye — such,  for  example,  as  intense  conjunctivitis  lasting  forty- 
five  days.  Another  case  showed,  twenty  days  after  the  ocular  reaction,  ex- 
tensive interstitial  keratitis  with  iritis.  Satterlee  reports  a  serious  result 
follo\Aang  the  instillation  of  a  1  per  cent,  tuberculin  solution  in  the  eye. 

Method  of  Inoculation. — Scarify  three  small  areas  of  skin,  but  not 
sufficiently  to  produce  a  bleeding  surface.  Inoculate  a  small  drop  of  cUluted 
or  pure  tuberculin  into  two  of  the  scarified  areas,  and  leave  the  third  area 
as  a  control  without  inoculating.  The  method  pursued  should  be  similar 
to  the  one  ordinarily  employed  in  vaccination.  The  solution  used  should 
consist  of  Koch's  old  tuberculin,  1  part,  sterile  water,  3  parts;  or  Koch's 
pure  tuberculin-old.  Inoculate  two  of  the  scarified  areas,  leaving  the  third 
area  as  a  control.  Von  Pirciuet*  uses  one  part  of  tuberculin  diluted  with 
one  part  of  a  5  per  cent,  carbolic  glycerin  and  two  parts  of  a  physiological 
salt  solution,  employing  the  same  method  of  inoculation  as  that  just  de- 
scribed. 

The  reaction  is  the  result  of  a  combination  of  the  toxin  with  antibodies. 
A  noteworthy  point  is  that  in  infants  the  reaction  disappears  witliin  three 
to  four  days,  and  it  is  safe,  therefore,  to  inoculate  again  after  a  few  days. 
In  older  children  the  reaction  is  visible  for  several  weeks.  In  one  of  my 
cases  a  positive  reaction  was  visible  for  three  weeks.  I  have  inoculated 
more  than  100  cases,  and  have  not  seen  a  single  unfavorable  result  follow. 
Neither  the  epitrochlear  nor  the  axillary  glands  were  enlarged  at  any  time 
after  the  inoculation. 

In  my  service  at  the  Sydenham  Hospital  (cliildren's  ward),  the  following 
series  of  cases  were  inoculated  during  the  spring  and  summer  of  1908: 

Name.  Age  Clinical  Diagnosis.  Result  of  von  Pirquet  Test. 

Z.  K Ih  years.  Lobar  pneumonia Negative. 

P.  A 4    months.  Marasmus,  empyema " 

I.  W 2  "  Congenital  defect  of  ears " 

S.  S 2^  years  Erythroderma  desquamativa " 

H.  F 5  "  Tuberculous  hip Positive. 

L.  L 5   weeks.  Bronchopneumonia,  marasmus Negative. 

K.  L 8    years.  Catarrhal  appendicitis " 

G.  W 10    months.  Lobar  pneumonia " 

A.  C 5    years.  Tuberculous  osteomyelitis Positive. 

C.  S 3    months.  Purulent  bronchitis Negative. 

C.  W 5    years.  General  bronchitis " 

G.  A 1|        "  Lobar  pneumonia " 

A.  D 3    months.  Marasmus " 

B.  P 3    days.  Normal " 

H.  Z 6    months.  Rachitis " 

A.  B 3    weeks.  Feeding " 

M.  M 5    years.  Tuberculous  hip Positive. 

*  In  1908,  while  making  the  rounds  with  Dr.  C.  von  Pirquet  in  the  St.  Anna  Chil- 
dren's Hospital  of  Vienna,  I  noted  that,  instead  of  diluted  tuberculin,  the  pure  tuber- 
culin (alt  Tuberculin,  Koch)  is  used. 


TUBERCULIN   TESTS   IN   INFANTS   AND    CHILDREN. — FISCHER. 


583 


Name.  Age. 

M.  G 6    months. 

W.  K 3    weeks. 

D.  G 2    years. 

F.  H 8    months. 

C.  R 16 

S.  A 7 

L.  S 16 

M.  F 4 

F.  U 10 

A.  B 2^  years. 

L.  R 8 

J.  P U 

C.  P 14 

J.  A 17 

M.  F 9 

M.  S 6    weeks. 

M.  S 8    months. 


Clinical  Diagnosis.  Result  of  von  Pirquet  Test. 

Marasmus Negative. 

Marasmus " 

Bronchopneumonia " 

Cervical  adenitis " 

Hydrocephalus " 

Bronchopneumonia " 

Bronchopneumonia " 

Gastro-enteritis " 

Gastro-enteritis " 

Tuberculous  meningitis Positive. 

Sarcoma  of  kidney Negative. 

Cerebrospinal  meningitis Positive. 

Apex  tuberculosis " 

Bone  tuberculosis " 

Malnutrition Negative. 

Bronchopneumonia " 

Miliary  tuberculosis Positive. 


The  last  case  was  iDroved  post  mortem. 


Name. 

S.  B.  . 
W.  H. 
C.  W. 


T.  W. 
M.  B. 
M.  H. 
L.  G. 


Age. 
.15     mo. 
.    4    yrs. 
.   6    mo. 


R.  E...  .11    yrs. 


1  yr. 

14  mo. 

18  " 

10  " 


Family  History. 
Negative. 

Mother  pulmon- 
ary tubercu- 
losis. 

Father  died  of 
tuberculosis. 

Negative. 


Clinical  Diagnosis. 
Lobar  pneumonia. 
Cerebrospinal  meningitis. 
G  astro-enteritis . 


Gastro-enteritis. 

Bronchopneumonia. 
Lobar  pneumonia. 
Bronchopneumonia. 
Bronchopneumonia. 


Reaction. 
Negative. 

a 

Positive. 


Doubtful. 
Negative. 


Negative  areas  of 
Consolidation  in 
both  lungs;  no 
evidence  of  tuber- 
culosis.   Autopsy. 


E.  G.. 

..  7 

i< 

(( 

Bronchopneumonia. 

Negative. 

F.  B.. 

.  .  V 

Bronchopneumonia. 

R.  S.. 

..10 

Mother 
ary 
losis. 

pulmon- 
tubercu- 

Broncliopneumonia. 

Positive. 

J.  Z.  . 

..14 

ft 

Negative. 

Gastro-enteritis. 

Negative. 

T.  R.. 

..   6 

yrs. 

Lobar  pneumonia. 

(( 

S.  K.. 

..10 

" 

(( 

Chorea. 

« 

M.  J.. 

..20 

mo. 

<( 

Gastro-enteritis. 

(( 

R.  R.. 

..   4 

(( 

« 

Hydrocephalus. 

tt 

J.  W.. 

..   6 

yrs. 

<< 

Tubercular  peritonitis. 

Positive  laparotomy, 
excision  of  cheesy 
glands.     Tubercu- 
losis found. 

S.  F.  . 

.  .   2* 

(( 

« 

Gastro-enteritis. 

Negative. 

J.  F.  . 

.  .12 

IC 

(( 

Typhoid. 

K 

L.  M.. 

..20 

mo. 

C( 

Gastro-enteritis,   bronchi- 
tis, otitis  media. 

(( 

Y.  F.. 

..   0 

(( 

(( 

Gastro-enteritis. 

<< 

In  my  series  of  55  cases  here  reported  there  were  three  autopsies.     In 
the  one  case  in  which  a  positive  reaction  occurred  a  general  miliary  tuber- 


584  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

culosis  was  found.  In  a  second  case  the  diagnosis  of  lobar  pneumonia  was 
made  intra  vitam,  and  a  negative  reaction  was  obtained.  The  post-mortem 
examination  showed  lobar  pneumonia  and  no  evidence  of  tuberculosis.  In 
a  third  case,  that  of  a  ten  months'  old  cliild  who  died  of  bronchopneumonia, 
the  von  Pirquet  reaction  was  negative.  The  post-mortem  examination 
showed  no  evidence  of  tuberculosis. 

In  this  last  group  of  cases  there  are  three  distinct  evidences  of  tuber- 
culosis in  the  family  history.  Two  of  the  children  from  these  families  gave 
a  positive  cutaneous  reaction  and  the  third  a  doubtful  reaction. 

NUMBER  OF  CASES  OF  EACH  DISEASE. 

Lobar  pneumonia: 

1  child  less  than  one  year  old. 

4  children  between  one  and  two  years. 

1  child  at  six  years  old. 
Cerebrospinal  meningitis : 

1  child  between  one  and  two  years. 

1  child  at  4  years  old. 
Gastro-enteritis: 

4  children  less  than  one  year  old. 

3  children  between  one  and  two  years. 

1  child  between  two  and  three  years. 

1  child  at  eleven  years  old. 
Bronchopneumonia : 

7  children  less  than  one  year  old. 

1  child  at  one  year  old. 

1  child  at  two  years  old. 

2  children  between  one  and  two  years. 


Chorea: 
Hydrocephalus: 


1  child  at  ten  years  old. 


1  child  less  than  one  year  old. 

1  child  between  one  and  two  years. 
Tuberculous  peritonitis: 

1  child  at  six  years  old. 
Typhoid: 

1  child  at  twelve  years  old. 
Marasmus: 

4  children  less  than  one  year  old. 
Congenital  defect  of  ears: 

1  child  less  than  one  year  old. 
Erythroderma  desquamativa: 

1  child  less  than  one  year  old. 
Tuberculous  hip: 

2  children  at  five  years  old. 
Catarrhal  appendicitis: 

1  child  at  eight  years  old. 
Tuberculous  osteomyelitis: 

1  child  at  five  years  old. 
General  bronchitis: 

1  child  at  five  years  old. 
Normal: 

1  child  less  than  one  year  old. 
Rachitis: 

1  child  less  than  one  year  old. 
Feeding: 

1  child  less  than  one  year  old. 


TUBERCULIN   TESTS   IN   INFANTS   AND    CHILDREN. — FISCHER.  585 

Cervical  adenitis: 

1  child  less  than  one  year  old. 
Tuberculous  meningitis : 

1  child  between  one  and  two  years^ 
Sarcoma  of  kidney: 

1  chUd  at  eight  years  old. 
Apex  tuberculosis: 

1  child  at  fourteen  years  old. 
Bone  tuberculosis: 

1  child  at  seventeen  years  old. 
Malnutrition: 

1  child  at  nine  years  old. 
]\Iiliary  tuberculosis: 

1  child  less  than  one  year  old. 
Purulent  bronchitis: 

1  child  less  than  one  year  old. 

In  the  foregoing  group  of  cases  8  children  suffered  with  lobar  or  lobular 
pneumonia  in  which  a  positive  diagnosis,  excluding  tuberculosis,  was  hardly 
possible  intra  vitani.  With  the  aid  of  the  von  Pirquet  inoculation  a  negative 
reaction  showed  the  probable  absence  of  tuberculous  infection.  In  a  case 
of  coxitis  a  positive  reaction  strengthened  the  diagnosis  of  tuberculous  hip. 
Another  positive  reaction  was  found  in  a  case  of  osteomyelitis  of  the  foot. 

Value  of  the  Reaction. — The  presence  of  a  positive  reaction  means 
that  we  are  dealing  with  a  probable  tuberculosis.  Equally  important, 
therefore,  is  the  absence  of  this  reaction — the  so-called  "negative  reaction," 
by  which  we  can  exclude  tuberculosis.  In  some  cases  a  reinoculation  is 
indicated  because  some  children  respond  slowly  and  give  tardy  reactions. 

Limitations. — The  younger  the  child,  especially  if  it  is  between  infancy 
and  its  third  year,  the  more  valuable  and  the  more  reliance  should  be  placed 
upon  the  presence  or  absence  of  the  von  Pirquet  reaction.  We  must  not 
expect  too  much  from  the  inoculation  with  tuberculin,  and  no  one  should 
make  a  diagnosis  of  tuberculosis  based  on  a  positive  cutaneous  reaction 
alone.  When  symptoms  of  malaise  and  general  breaking  down  are  noted, 
or  when  symptoms  of  malaria  exist,  the  absence  of  the  plasmodium  in  the 
blood  with  a  positive  von  Pirquet  reaction  would  strongly  support  the 
diagnosis  of  tuberculosis  and  exclude  malaria.  In  other  words,  no  one 
symptom  should  be  used  to  make  a  diagnosis  unless  it  is  supported  by 
systemic  manifestations,  in  which  tuberculous  suspicion  exists. 

The  presence  of  the  Klebs-Loffler  bacillus  in  the  mouth,  or  the  presence 
of  the  pneumococcus  in  the  throat,  does  not  justify  the  diagnosis  of  diph- 
theria or  pneumonia  unless  accompanied  by  clinical  evidences  of  each 
distinct  disease.  In  like  manner  no  one  should  isolate  a  patient  and  call 
him  tuberculous,  basing  the  diagnosis  on  the  cutaneous  manifestation 
alone,  without  supporting  evidence  of  organic  or  local  infection  giving 
distinct  suspicion  of  a  tuberculous  process. 

I  have  previously  stated  that  this  reaction  is  not  found  in  the  last  stages 


586  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

of  miliary  tuberculosis  nor  in  tuberculous  meningitis,  because  at  such  times 
the  condition  of  the  system  is  so  markedly  transformed  that  there  is  a 
tolerance  of  the  maximum  doses  of  tuberculin  without  apparent  effect. 
In  some  children  it  is  wise,  if  the  first  inoculation  proves  negative,  again  to 
inoculate  after  one  or  two  weeks.  Von  Pirquet  reports  a  first  inoculation 
as  negative,  whereas  the  second  one  was  positive  in  his  series  of  cases. 

Accidents  Resulting  from  Inoculation. — In  my  own  experience 
in  the  hospital  and  cases  seen  in  private  practice  there  has  never  been  an 
accident  following  the  inoculation  with  tuberculin.  This  same  absence 
of  untoward  results  was  noted  by  me  while  studying  this  method  in  several 
hospitals  in  Berlin  and  Vienna  during  the  summers  of  1907  and  1908.  The 
resident  staff  of  the  Sydenham  Hospital  report  not  a  single  accident  nor 
infection  following  the  von  Pirquet  method.  The  simplicity  of  the  method 
and  the  excellent  after-effects  are  sufficient  in  themselves  to  justify  a  more 
general  acceptance  of  this  diagnostic  aid.  The  von  Pirquet  reaction  is  of 
great  value  in  estimating  a  prognosis.  It  is  absolutely  positive  as  a  diag- 
nostic aid  in  early  infancy.  It  is  of  great  assistance  in  strengthening  a 
diagnosis  of  tuberculosis  in  conditions  following  pertussis  or  measles. 

When  cei-vical  lymph-glands  are  enlarged,  or  when  enlarged  inguinal 
glands  are  palpable,  the  tuberculin  inoculation  renders  great  assistance  in 
excluding  local  inflammatory  conditions  from  general  tuberculous  mani- 
festation. 


Diagnostico  de  la  Tuberculosis  en  la  Ninez  per  Medio  de  las  Inoculaciones 
Cutaneas  de  la  Tuberculina  Diluida. — (Fischer.) 

El  diagnostico  de  la  tuberculosis  infantil  es  a  menudo  oscuro.  Aso- 
ciada  a  las  enfermedades  infecciosas  agudas  6  como  una  consecuencia  a 
ellas,  el  diagnostico  es  mas  dificil.  Manifestaciones  sifiliticas,  con  frecuencia, 
presentan  cuadros  clinicos  de  la  tuberculosis.  La  moculacion  cutanea  6  el 
metodo  de  von  Pirquet,  ha  probado  ser  una  ayuda  en  la  sospecha  de  la 
tuberculosis  latente.  La  reaccion  optalmica  de  Calmette  ha  dado  graves 
complicaciones  del  ojo,  en  America  y  en  Europa.  La  reaccion  de  Pirquet 
no  presenta  tales  complicaciones. 

Despues  de  escarificar  tres  areas  pequenas  de  la  piel,  dos  de  las  cuales 
solamente  son  inoculadas,  la  reaccion  es  positiva  si  a  las  24  horas  6  a  mas 
tardar  a  las  48  horas,  se  observa  una  elevacion  como  de  diez  milimetros  de 
ancho,  no  hay  elevacion  de  la  temperatura,  frio  ni  disturbios  del  organism©. 
Si  la  primera  inoculacion  no  presentare  una  reaccion  positiva,  una  segunda 
puede  hacerse  sin  peligro  de  complicaciones.  Si  la  reacci6n  es  positiva, 
esta  sera  visible  durante  siete  dias  en  los  recien  nacidos.     En  los  ninos  de 


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TUBERCULIN   TESTS   IN   INFANTS   AND    CHILDREN. — FISCHER.  587 

mayor  edad  la  reaccion  permanece  por  algunas  semanas.  La  reaccion  fue 
positiva  en  la  meningitis  tuberculosa,  en  tuberculosis  de  la  articulacion  de 
la  cadera,  ostitis  tuberculosa  y  tuberculosis  pulmonar. 


Diagnose  der  Tuberkulose  im  Sauglingsalter  und  in  der  Kindheit  durch 
die  Hautinoculation  von  Tuberkulin. — (Fischer.) 

Die  Diagnose  der  Sauglingstuberkulose  ist  haufig  obscur.  In  Ver- 
bindung  mit  den  acuten  Infectionskrankheiten  oder  als  eine  Folge  derselben 
ist  die  Diagnose  schwer  zu  machen.  Syphilitische  ausserungen  zeigen  oft 
klinische  Bilder,  die  der  Tuberkulose  sehr  ahnlich  sind.  Die  Inoculation 
nach  der  cutanen  oder  von  Pirquet'schen  Methode  hat  sich  als  eine  Hilfe 
in  der  Starkung  des  Verdachtes  auf  latente  Tuberkulose  erwiesen.  Die 
Ocular-Reaction  von  Calmette  ist  von  schweren  Augencomplicationen 
sowohl  hier  als  auch  jenseits  des  Ozeans  begleitet  gewesen.  Keine  derartige 
Gefahr  ist  mit  von  Pirquets  Methode  berichtet  worden. 

Nachdem  drei  kleine  Hautflachen  aufgeschiirft  worden  sind,  von  denen 
zwei  inoculirt  werden  und  die  dritte  zur  Controlle  iibrigbleibt,  sollte  in  24 
oder  spatestens  48  Stunden  eine  erhohte  Papel  von  ungefahr  10  Millimetem 
Weite  gefunden  werden  was  eine  positive  Reaction  genannt  werden  kann. 
Es  kommt  zu  keiner  Temperatursteigerung,  Schiittelfrost,  oder  allgemeinen 
Storungen  des  Systems.  Es  sind  auch  keine  unangenehmen  Nacherschein- 
ungen  berichtet  worden.  Wenn  nach  der  ersten  Inoculation  keine  Reaction 
auftritt,  dann  mag  einige  Wochen  spater  eine  zweite  Inoculation  gegeben 
werden,  ohne  irgend  welche  Gefahr  oder  iible  Folgen.  Wenn  die  Reaction 
positiv  ist,  wird  sie  bei  jungen  Kindern  5  bis  7  Tage  sichtbar  sein.  Bei 
alteren  Kindern  wird  sie  manchmal  mehrere  Wochen  lang  vei^weilen.  Die 
Reaction  war  positiv  in  tuberkuloser  Meningitis,  tuberkuloser  Coxitis,  als 
auch  in  Lungentuberkulose  und  tuberkuloser  Osteomyelitis. 


DIAGNOSTIC  VALUE  OF  LUMBAR  PUNCTURE  IN  ACUTE 
TUBERCULOUS  MENINGITIS  OF  CHILDREN. 

By  Frederic  E.  Sondern,  M.D., 

Professor  of  Clinical  Pathology,  New  York  Post-Graduate  Medical  School.     Director  of  The  Clinical 
Laboratory,  New  York  Lying-in  Hospital. 


Accurate  methods  of  examination  of  the  cerebrospinal  fluid  are  doubtless 
of  very  material  benefit  in  diagnosis  and  differential  diagnosis.  While  the 
bacteriological  examination  has  rendered  the  most  brilliant  results  in  positive 
diagnostic  data,  and  perfected  technic  has  further  advanced  the  efficiency 
of  this  single  analytical  procedure,  there  is  still  an  uncomfortably  large 
number  of  cases  of  tuberculous  meningitis  in  which  the  bacilli  cannot  be 
found. 

In  view  of  the  great  similarity  in  the  symptomatology  of  meningeal 
lesions,  it  is  essential  that  all  possible  information  should  be  gained  from 
the  cerebrospinal  fiuid.  The  bacteriology  and  the  cytology  certainly  pre- 
sent the  most  valuable  information,  but  as  the  laboratory  examination  of 
the  cerebrospinal  fluid  is  still  in  a  state  of  evolution  and  many  polemic 
points  exist,  it  is  necessary  that  the  procedure  be  made  as  complete  as 
possible.  The  pressure,  appearance,  density,  amount  of  albumin,  and  other 
chemical  data,  the  amount  of  sediment,  the  tendency  to  coagulation,  the 
toxicity,  the  freezing-point,  and  the  transmission  of  some  administered 
drugs  to  the  cerebrospinal  fluid  may  be  determined.  As  yet  the  additional 
information  thus  obtained  cannot  be  considered  very  satisfactory,  although 
it  is  at  times  of  value  as  corroborative  evidence.  Current  literature  presents 
many  conflicting  views,  some  far  too  enthusiastic  and  others  in  which 
evident  lack  of  precision  is  the  reason  why  the  procedure  is  condemned  as  a 
diagnostic  measure.  As  in  other  clinical  laboratory  work,  the  information 
obtained  often  establishes  a  diagnosis,  but,  failing  this,  it  invariably  fur- 
nishes data  that  are  of  use  in  tentative  diagnosis  and  particularly  in  diag- 
nosis by  exclusion. 

The  finding  of  tubercle  bacilli  in  the  cerebrospinal  fluid  is  the  greatest 
aid  the  laboratory  can  render  in  the  diagnosis  of  tuberculous  meningitis, 
but  in  their  absence  it  is  essential  that  as  much  corroborative  evidence  as 
possible  be  obtained,  and  particularly  facts  that  will  exclude  lesions  that 
are  in  question  in  the  differential  diagnosis.     It  is  to  a  brief  consideration 

588 


DIAGNOSTIC    PUNCTURE    IN   ACUTE   MENINGITIS. — SONDERN.  589 

of  the  technic  and  results  obtained  from  these  analytical  procedures  that 
I  invite  your  attention. 

Experience  teaches  that  the  common  error  the  clinician  is  likely  to 
make,  in  this  as  well  as  in  other  laboratory  investigations,  is  that  of  at- 
tempting solely  to  corroborate  the  clinical  opinion,  and  failing  in  this, 
to  abandon  the  examination.  No  matter  how  conclusive  the  clinical  picture, 
if  the  laboratory  examination  of  the  specimen  is  to  be  made  at  all,  it  should 
include  at  least  all  valuable  points;  if  the  actual  diagnostic  factor  is  not 
found,  some  corroborative  evidence  is  certainly  present.  On  the  other 
hand,  indications  of  lesions  may  be  found  that  may  overthrow  the  tentative 
clinical  diagnosis. 

Bacteriological  Examination. — Opinions  concerning  the  frequency 
with  which  tubercle  bacilli  are  found  in  the  cerebrospinal  fluid  in  cases  of 
tuberculous  meningitis  vary  within  considerable  range,  though  most  of  the 
recent  reports  are  decidedly  more  favorable  than  the  older  ones.  Heubner 
claimed  that  bacilli  are  present  only  in  exceptional  cases,  and  in  a  recent 
article  by  Gindes*  he  states  that  they  are  difficult  to  find  early  in  the  disease, 
at  a  time  when  this  information  is  of  the  most  use.  On  the  other  hand, 
Lichtheim  and  also  Breuer  f  succeeded  in  finding  bacilli  in  all  cases  examined. 
Most  observers  class  their  results  between  these  extremes.  FriedjungI 
states  that  they  are  difficult  to  find  early,  and  are  frequently  present  later 
in  the  disease.  Pfaundler  §  finds  them  early  in  33  per  cent,  of  cases,  and  in 
75  per  cent,  of  all  cases.  An  average,  figured  from  the  results  quoted  in 
six  other  publications,  is  69.5  per  cent,  of  all  cases.  Koplik||  calls  attention 
to  the  important  point  that  painstaking  search  is  an  essential  feature  of 
success.  In  his  earlier  work  bacilli  were  found  in  64  per  cent,  of  the  cases, 
whereas  during  the  last  few  years  they  were  found  in  89  per  cent.,  and  were 
demonstrated  on  inoculation  in  all  the  rem.aining  cases  of  the  latter  group. 
My  personal  experience  is  limited  to  29  specimens  from  27  cases  in  private 
practice,  where  the  subsequent  course  of  the  disease  and  autopsy  in  4  cases 
justified  the  clinical  diagnosis  of  tuberculous  meningitis.  In  22  the  bacilli 
were  found  on  the  first  examination.  In  2  others  the  bacilli  were  found  on 
the  second  examination.  The  percentage  of  positive  results  is  thus  88  per 
cent.,  or  practically  what  Koplik  made  it  in  his  later  series. 

Concerning  the  technic,  numerous  observers  have  made  the  suggestion 
that  it  is  better  to  spread  the  coagulum  for  purposes  of  staining  than  to 
use  the  centrifuged  sediment  and  not  the  coagulum.  My  experience,  how- 
ever, is  that  the  best  results  are  obtained  from  a  centrifuged  sediment  be- 

*  E.  J.  Gindes:  Arch.  f.  Kinderheilkunde,  1907. 

t  Breuer:  Wien.  klin.  Rundschau,  1901. 

X  Friedjung:  Wien.  klin.  Wochensch.,  1901. 

§  Pfaundler:  Beitrage  z.  klin.  Med.  u.  Chir.,  1899. 

II  Koplik:  Jour.  Amer.  Med.  Assoc,  June  2i,  1907. 


590  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

fore  coagulation  occurs,  or  if  a  clot  has  formed,  from  the  employment  of 
the  practice  of  inoscopy,  as  recommended  by  Jousset*  or  Zebrowski.f 
The  specimens,  however  prepared,  should  be  stained  and  decolorized  in  the 
usual  manner,  but  not  counterstained.  The  absence  of  a  counterstain  is 
particularly  desirable  when  a  prolonged  search  has  to  be  made.  All  speci- 
mens should  also  be  examined  for  other  organisms,  even  if  tubercle  bacilli 
are  present,  as  the  presence  of  a  mixed  infection  is  not  only  of  importance  in 
a  consideration  of  the  case,  but  may  explain  why  the  cytology  of  the  cere- 
brospinal fluid  and  the  result  of  a  blood  examination  do  not  correspond  to 
what  is  usually  found  in  tuberculous  meningitis. 

By  those  who  have  used  it  to  any  extent,  the  inoculation  test  is  considered 
positive  in  every  instance,  the  sole  objection  to  its  use  being  the  time  re- 
quired to  learn  the  result.  This  objection,  in  all  but  exceptional  cases, 
renders  it  useless,  and  a  quicker  and  just  as  accurate  a  result  may  be  ob- 
tained by  the  direct  search  for  bacilli,  repeated  as  often  as  may  be  necessary. 
Although  bacilli  may  not  be  found  in  the  first  or  second  specimen,  it  is 
reasonable  to  believe  that  subsequent  examinations  will  disclose  their 
presence  long  before  the  positive  outcome  of  an  inoculation  test  becomes 
apparent. 

In  this  connection  the  recent  article  by  MuchJ  may  be  of  interest.  He 
asserts  that  there  are  forms  of  tubercle  bacilli  that  are  not  acid  proof,  and 
consequently  do  not  stain  by  the  usual  methods  employed.  If  these  obser- 
vations are  correct,  they  may  explain  why  tubercle  bacilli  are  sometimes  not 
found  in  obviously  tuberculous  lesions,  and  also  the  difficulties  encountered 
in  the  demonstration  of  these  organisms  in  the  cerebrospinal  fluid. 

Cytology. — The  morphological  study  of  the  leukocytes  in  the  cere- 
brospinal fluid  has  resulted  in  giving  us  some  rather  definite  diagnostic  data. 
This  is  by  no  means  so  conclusive  in  any  instance  as  the  finding  of  the 
causative  organism,  but  it  is  always  helpful  and  stimulates  the  search  in 
one  or  other  particular  direction  for  bacteria,  as  well  as  for  conclusive  clinical 
signs.  The  essential  facts  are  the  relative  prevalence  of  lymphocytes  or 
of  polynuclear  cells,  but  one  must  not  fall  into  the  error  of  believing,  as  is 
so  often  stated,  that  lymphocytes  indicate  tuberculosis,  and  polynuclear 
cells  an  acute  pyogenic  process,  for  there  have  been  too  many  exceptions 
found  to  this  crude  rule.  The  significance  of  a  relative  lymphocyte  increase 
or  of  a  polynuclear  cell  increase  depends  on  a  number  of  factors,  the  careful 
consideration  of  which  determines  the  value  of  the  cyto  count  in  the  given 
ease. 

The  results  are  most  accurate  in  fully  developed  acute  cases  of  meningitis, 
less  so  in  the  very  early  stages,  and  still  less  so  in  the  later  stages  or  during 

*  Jousset:  La  semaine  mM.,  1903.  t  Zebrowski:  Deut.  med.  Woch.,  1905. 

J  Much:  Beitrage  z.  Klinik  d.  Tuberculose,  viii. 


DIAGNOSTIC    PUNCTURE   IN    ACUTE   MENINGITIS. — SONDERN.  591 

convalescence,  as  the  case  may  be.  In  the  fully  developed  acute  stage  of 
meningitis  an  excess  of  lymphocytes  tends  to  indicate  a  tuberculous  process, 
whereas  an  increase  in  the  relative  number  of  polynuclear  cells  would  speak 
rather  for  a  meningitis  due  to  streptococci,  staphylococci,  pneumococci,  or 
meningococci,  the  differential  diagnosis  depending  on  the  bacteria  found. 

While  a  relative  lymphocyte  increase,  under  the  circumstances  cited, 
is  suggestive  of  tuberculosis,  in  the  absence  of  tubercle  bacilli  the  following 
exceptions  must  be  kept  in  mind.  Typhoid  fever  with  meningeal  symptoms 
and  ^\ithout  a  mixed  infection  will  show  a  relative  lymphocyte  increase, 
usually  without  bacteria,  as  long  as  the  symptoms  last.  ]\Ieningism  ac- 
companying pneumonia,  mumps,  and  numerous  other  diseases  in  children, 
if  there  is  an  increase  of  leukocytes  in  the  cerebrospinal  fluid,  will  at  first 
also  show  an  excess  of  lymphocytes  and  no  organisms;  if  tliis  condition 
develops  into  a  true  meningitis,  the  polynuclear  cells  then  show  a  relative 
increase,  and  the  etiological  bacteria  are  found.  It  seems  more  difficult  to 
explain  why  a  relative  polynuclear  increase  should  sometimes  occur  in 
tuberculous  meningitis.  I  have  met  this  exception  in  one  case  only,  and 
was  able  to  demonstrate  a  mixed  infection  of  tubercle  bacilli  and  pneumo- 
cocci. It  is,  however,  described  in  a  relatively  small  number  of  cases  by 
most  observers,  and  constitutes  the  chief  reason  why  the  value  of  cytology 
has  been  discrecHted,  as,  for  example,  by  IMiitzner.  The  existence  of  a 
mixed  infection  would  seem  to  be  the  most  plausible  way  to  explain  this 
anomaly,  and  this  is  also  the  belief  of  Ross,*  who  has  found  evidences  of  it 
in  a  number  of  cases,  and  of  Frank  Eve,  of  Hull,  who  obtained  staphylococci 
in  cultures  from  these  cases  of  tuberculous  meningitis,  verif}dng  the  diagnosis 
at  autopsy. 

It  seems  unfortunate  that,  in  a  large  number  of  publications  in  reference 
to  cytology  as  a  diagnostic  factor,  there  are  comparatively  few  citations  of 
the  actual  figures  obtained.  My  series  of  15  counts  in  tuberculous  meningi- 
tis shows  the  following: 

Lymphocytes.  Polynuclear  Cells. 

1 88  per  cent.  12  per  cent. 

2 75  "  25 

3 96  "  4 

4 90  "  10 

5 82  "  18   " 

6 77  "  23 

7 97  "  3 

8 82  "  18 

9 96  "  4   " 

10 28  "  72   " 

11 80  "  20 

12 68  "  32   " 

13 97  "  3   " 

14 90  "  10   " 

15 88  "  12   " 

*  Ross:  Brit.  Med.  Jour.,  September  21,  1907,  p.  742. 


592  SIXTH    INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

Excluding  the  No.  10  count,  which  was  the  cited  case  in  which  evidences 
of  a  mixed  infection  were  found,  the  average  lymphocyte  percentage  was 
86.  Koplik,*  in  detailing  the  results  obtained  in  19  specimens,  finds  that 
17  of  these  the  relative  percentage  of  lymphocytes  was  over  70.  The  degree 
of  increase  of  the  one  or  other  variety  of  leukocyte  should  always  be  noted, 
as  I  believe  further  experience  will  attach  importance  thereto.  For  exam- 
ple, in  the  case  of  mixed  infection  quoted  the  polynuclear  percentage  was 
72,  which  is  considerably  lower  than  what  we  usually  find  in  non-tuberculous 
meningitis  of  one  or  other  type.  Obviously,  a  large  amount  of  additional 
data  will  be  necessary  before  conclusions  on  tlus  point  are  justified. 

A  consideration  of  cytological  changes  at  times  other  than  in  the  fully 
developed  acute  stage  of  a  meningitis  would  take  us  too  far  afield,  and, 
unfortunately,  to  little  or  no  purpose. 

Concerning  the  technic,  slides,  and  not  cover-glasses,  should  be  thinly 
spread  with  the  sediment,  and  stained  with  one  of  the  polychrome  blood- 
stains that  should  be  diluted.  I  prefer  a  mixture  of  Jenner  and  Wright,  on 
account  of  obtaining  the  more  distinct  nuclear  stain  of  the  former,  and  the 
clear  neutrophilic  granulations  of  the  latter. 

Pressure  of  the  Cerebrospinal  Fluid. — Several  simple  and  ingenious 
methods  have  been  devised  for  the  determination  of  the  pressure,  and  a 
number  of  observations  have  been  published;  for  example,  those  of  Quincke, f 
Sicard,  and  Kronig.|  It  is  generally  believed,  however,  that  those  prac- 
tising lumbar  puncture  soon  learn  to  form  an  opinion  as  to  the  approximate 
degree  of  pressure,  which  is  generally  increased  in  direct  ratio  to  the  extent 
of  exudation.  The  clinically  important  point  is  that  increased  pressure  is 
significant;  but  the  accuracy  obtained  by  the  use  of  a  manometer  is  not 
necessary,  particularly  as  the  pressure  in  the  tapping  instrument  is  often  no 
guide  to  the  pressure  above,  on  account  of  frequent  obstructions.  Tscher- 
noff  is  quoted  by  Gindes  as  saying  that  a  serous  meningitis  remains  a  serous 
meningitis  be  the  pressure  15  mm.  or  120  mm.,  and  this  seems  a  sensible 
argument.  For  practical  purposes,  then,  the  pressure  noted  on  puncture 
serves  as  a  guide  to  the  amount  of  accumulated  exudate,  provided  no 
obstruction  to  the  flow  exists. 

Appearance. — In  typical  cases  of  tuberculous  meningitis  the  fluid  is 
perfectly  transparent  and  colorless.  I  have  found  no  exception  to  this  rule 
except  in  the  case  of  mixed  infection,  but  Friedjung§  claims  to  have  ob- 
served considerable  turbidity,  and  G.  C.  Robinson  ||  also  speaks  of  a  slight 
opalescence  and  turbidity.  In  meningitis  due  to  the  meningococcus  and 
the  pneumococcus  the  fluid  is  usually  turbid,  and  in  the  presence  of  pyo- 
genic organisms  it  is  often  distinctly  purulent. 

*  Koplik:  Loc.  cit.  t  Quincke:  Berlin,  klin.  Woch.,  1891. 

X  Kronig;  Berlin,  klin.  Woch.,  1897.  §  Friedjung:  Loc.  cit. 

II  Robinson:  Bull.  Ayer  Clin.  Laboratory,  No.  4. 


DIAGNOSTIC   PUNCTUHE   IN   ACUTE   MENINGITIS. — SONDERN.  593 

Density  and  Molecular  Concentration. — The  specific  gravity, 
which  is  normally  about  1006,  is  increased  in  meningitis,  as  in  other  serous 
exudates,  in  proportion  to  the  increase  in  the  amount  of  albumin.  The 
same  applies  to  the  degree  of  molecular  concentration,  as  determined  by 
cryoscopy.  Both  of  these  procedures  are  of  value  in  the  differential  diagnosis 
of  afebrile  chronic  brain  lesions,  but  are  quite  secondary  in  the  condition 
under  discussion. 

Chemistry. — The  amount  of  albumin  is  increased  in  all  acute  inflam- 
matory meningeal  lesions  and  in  tuberculous  meningitis,  offering  but  little, 
if  any,  aid  in  their  differential  diagnosis.  It  is,  for  example,  low  in  some 
cases  of  chronic  hydrocephalus,  slowly  developing  brain  tumors,  and  in 
some  cases  of  serous  meningitis,  and  high  in  other  cases  of  hydrocephalus 
and  in  the  acute  conditions  mentioned.  In  the  15  specimens  from  cases  of 
tuberculous  meningitis  the  maximum  found  was  approximately  2  parts 
per  mille  by  weight,  and  the  minimum  approximately  f  per  mille  by  weight. 
Other  observers  report  both  higher  and  lower  figures.  Other  chemical 
problems,  such  as  the  amount  of  urea,  the  presence  of  sugar,  and  the  pres- 
ence of  cholin  are  engaging  the  attention  of  the  scientist,  but  are  as  yet  of 
no  established  practical  value,  particularly  in  the  condition  that  now  en- 
gages our  attention. 

Sediment. — The  amount  of  sediment  in  tuberculous  meningitis  is  usu- 
ally quite  slight.  This  feature  serves,  to  some  extent,  as  a  differential 
point,  and  has  led  to  efforts  to  determine  scientifically  the  number  of  cells 
in  a  given  amount  of  fluid,  by  much  the  same  method  as  is  used  in  the  ex- 
amination of  the  blood.  Fuchs  and  Rosenthal  have  constructed  a  special 
chamber  for  this  purpose,  and  Purves  Stewart  published  his  results  with  it. 
In  general  it  may  be  said  that  the  experienced  laboratory  worker  can  easily 
determine  if  an  increase  in  cells  is  present,  and  approximately  to  what 
degree.  The  additional  refinement  serves  about  as  little  practical  purpose 
as  the  determination  of  pressure  by  means  of  the  manometer,  as  previously 
mentioned. 

The  cytology  of  the  sediment  has  been  considered.  Aside  from  the 
bacteriology,  it  is  doubtless  the  most  important  feature  of  the  examination. 

The  occurrence  of  spontaneous  coagulation  in  the  specimen  was  formerly 
considered  an  absolute  indication  of  an  inflammatory  exudate,  and  was 
relied  upon  by  many  as  a  distinct  diagnostic  feature  in  meningitis.  This 
opinion,  though  still  held  by  many,  has  been  disturbed  by  the  publication 
of  cases  of  brain  tumor  and  consequent  stasis  in  which  distinct  coagulation 
of  the  cerebrospinal  fluid  occurred.  In  tuberculous  meningitis  the  coagulum 
is  usually  very  frail  and  spider-web  like,  whereas  in  acute  meningitis  of  other 
type  the  clot  is  generally  large  and  firm. 

Toxicity. — French  and  Italian  observers  have  devoted  considerable 


594  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

attention  to  the  toxicity  of  the  cerebrospinal  fluid,  but  as  yet  no  practical 
results  of  use  in  diagnosis  have  been  attained. 

Transmission  of  Administered  Drugs. — Griffon  and  Sicard  found 
that  they  could  recover  iodin  in  the  cerebrospinal  fluid  after  the  administra- 
tion of  potassium  iodid  in  normal  persons  and  in  cases  of  purulent  meningitis, 
whereas  there  was  no  such  transmission  in  cases  of  tuberculous  meningitis. 
Lehri  denies  this  emphatically,  and  von  Jaksch  claims  that  no  iodin  can  be 
demonstrated  under  any  circumstances.  The  subject  is  an  attractive  one, 
and  is  certainly  worthy  of  experiment. 

In  conclusion,  the  chief  diagnostic  and  differential  features  of  tuberculous 
meningitis  are  tabulated: 

Pressure :  Increased. 

Appearance:  Usually  transparent  and  colorless,  occasionally  slight 
opalescence. 

Density:  Not  much  increased. 

Albumin :  From  |  to  2  per  mille  by  weight. 

Coagulation:  Slight  and  frail. 

Sediment:  Slight. 

Cytology:  Average  number  of  lymphocytes,  86  per  cent. 

Bacteriology:  Tubercle  bacilU  found  in  about  88  j^er  cent. 

In  the  'presence  of  tubercle  bacilli  a  relative  polynuclear  cell  increase  should 
stimulate  the  search  for  organisms  of  a  second  or  mixed  infection,  particularly 
if  the  sediment  is  more  abundant  and  coagulation  pronounced. 

In  the  absence  of  tubercle  bacilli  and  other  organisms,  if  relative  lymphocyte 
increase  and  the  other  suspicious  signs  exist  in  an  acute  febrile  case,  re- 
peated search  for  baciUi  is  indicated,  and  the  other  causes  for  the  combina- 
tion should  be  kept  in  mind,  namely,  the  meningism  of  typhoid,  pneumonia, 
and  infectious  diseases. 

Abundant  sediment,  relatively  high  polynuclear  cell  count,  firm  coagu- 
lation, decidedly  increased  density,  and  large  amount  of  albumin  indicate 
a  purulent  meningitis,  and  the  causative  organism,  pneumococcus,  strepto- 
coccus, or  staphylococcus,  is  invariably  found.  The  differential  diagnosis 
between  this  class  of  cases  and  those  of  tuberculous  meningitis  never  offers 
any  difficulty. 

Cerebrospinal  meningitis  due  to  the  intracellular  diplococcus  sometimes 
presents  specimens  that  closely  resemble  those  from  a  tuberculous  meningi- 
tis. The  differentiating  points  are  that  the  relative  polynuclear  cell  increase 
is  high — usually  over  85  per  cent. — even  if  the  number  of  cells  present  is 
small,  and  that  the  characteristic  organisms  are  invariably  found,  according 
to  most  authors,  and  were  present  in  96  per  cent,  of  the  cases  in  my  series. 


DIAGNOSTIC   PUNCTURE   IN   ACUTE   MENINGITIS. — SONDERN.  595 

El  Valor  Diagndstico  de  la  Puntura  Lumbar  en  la  Meningitis  Tuberculosa 
Aguda  de  los  NLnos. — (Sondern.) 

El  examen  bacteriologico  del  fluido  cerebro-espinal  proporciona  el 
mejor  servicio  en  el  diagnostico,  aunque  el  examen  citologico  es  tambien 
importante,  particularmente  si  se  trata  de  los  casos  en  los  cuales  el  examen 
bacteriologico  da  un  resultado  negativo.  Los  informes  que  se  obtienen  de 
la  presion,  apariencia,  densidad,  la  tendencia  a  la  coagulacion,  las  propie- 
dades  toxicas,  del  fluido  y  la  trasmision  de  ciertas  drogas  administradas  en 
el  fluido  cerebro-espinal,  es  muchas  voces  de  un  valor  incontestable,  mas 
estos  son  secundarios  en  importancia.  El  examen  debera  ser  tan  complete 
como  las  circunstancias  y  la  cantidad  de  fluido  obtenido  lo  permita. 

El  diagnostico  principal  y  los  aspectos  diferenciales  son:  en  la  men- 
ingitis tuberculosa  la  presion  del  fluido  cerebro-espinal  es  aumentada; 
la  apariencia  por  lo  general  transparente  y  sin  color,  ocasionalmente  opale- 
sente;  la  densidad  no  es  notablemente  aumentada;  la  albumina  es  de  | 
y  2  por  mil  de  peso;  coagulacion  ligera  y  debil;  cedimento  ligero;  citologia, 
el  termino  medio  del  numero  de  linfocitos  es  de  86%;  bacteriologia,  el 
bacilo  de  la  tuberculosis  se  encuentra  en  88%  de  los  casos. 

Si  el  bacilo  de  la  tuberculosis  se  encuentra,  un  aumento  relativo  de  las 
celulas  polinucleares  indica  una  infeccion  mixta.  En  la  ausencia  del  bacilo, 
si  los  linfocitos  predominan,  el  examen  debera  repetirse,  y  debera  dirigirse  la 
atencion  a  la  posibilidad  de  una  meningitis  tifoidea,  neumonica,  etc.  Prue- 
bas  puiTilentas  por  lo  general  no  presentan  dificultad  en  el  diagnostico.  El 
aumento  relativo  de  las  celulas  polinucleares  y  la  casi  invariable  presencia  del 
diplococus  intra-celular,  sirve  de  diferencia  de  los  casos  de  la  meningitis 
cerebro-espinal. 

Valeur  diagnostique  de  la  piquure  lombaire  dans  la  meningite  tubercu- 
leuse  des  enfants. — (Sondern.) 

L'examen  bact^riologique  du  liquide  cer^bro-spinal  nous  rend  de  grands 
services  dans  le  diagnostic;  mais  la  cytologic  en  est  importante  aussi, 
surtout  quand  les  bacteries  en  sont  absentes.  Les  renseignements  sur  la 
pression,  I'apparence,  la  density,  la  quantite  de  I'albumine  et  les  autres 
donn^es  chimiques,  la  quantity  du  sediment,  la  tendance  a  la  coagulation, 
la  toxicity,  le  point  de  congelation  et  la  transmission  de  medicaments  ad- 
ministr^s  au  liquide  c^rebro-spinal,  tout  cela  a  souvent  une  valeur  decisive, 
mais  secondaire  a  l'examen  bact6riologique.  L'examen  doit  etre  aussi 
complet  que  le  permettent  les  circonstances  et  la  quantit(5  du  specimen 
obtenu. 

Les  principaux  signes  diagnostiques  et  diff6rentiels  sont :  Dans  la  mdnin- 


596  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

gite  tuberculeuse  la  pression  du  liquide  c^r^bro-spinal  est  augment^e,  le 
liquide  est  d'habitude  transparent  et  incolore,  parfois  legerement  opalin, 
la  densite  pas  beaucoup  augmentee,  Talbumine  pese  entre  0.75  et  2  pro  mille, 
le  coagulum  est  peu  volumineux  et  frele,  il  y  a  peu  de  sediment.  Comme 
cytologic,  le  nombre  moyen  des  lymphocytes  est  de  86%.  Concernant  la 
bacteriologie,  les  bacilles  de  la  tuberculose  sont  presents  dans  88%  des  cas. 

Si  des  bacilles  de  tuberculose  sont  presents,  une  augmentation  relative 
du  nombre  des  cellules  polynucleaires  pent  indiquer  une  infection  mixte. 
En  I'absence  des  bacilles,  si  les  lymphocytes  predominent,  il  faut  recom- 
mencer  I'examen,  et  on  ne  doit  pas  perdre  de  vue  la  possibilite  de  symp- 
tomes  meningitiques  d\Xs  a  la  fievre  typhoide,  a  la  pneumonic,  etc.  Les 
specimens  purulents  sont  g^neralement  faciles  a  diagnostiquer.  Enfin, 
les  cas  de  m6ningite  cerebro-spinale  se  distinguent  par  I'augmentation 
relative  du  nombre  des  cellules  polynucleaires  et  par  la  presence  presqu' 
invariable  des  diplococques  intracellulaires. 


Der  diagnostische  Wert  der  Lumbarpunktion  in  acuter  tuberkuloser 
Meningitis  bei  Kindern. — (Sondern.) 

Die  bacteriologische  Untersuchung  der  Cerebrospinalfliissigkeit  lei- 
stet  den  besten  Dienst  in  der  Diagnose,  obwohl  die  Zellkunde  auch  von 
Wichtigkeit  ist,  ganz  besonders  in  der  Abwesenheit  von  Organismen.  Die 
praktische  Information,  erhalten  von  Druck,  Erscheinung,  Dichtigkeit, 
Menge  von  Eiweiss  und  anderen  chemischen  Daten,  die  Menge  des  Sedi- 
ments, die  Tendenz  zur  Gerinnung,  die  Giftigkeit,  der  Gefrierpunkt  und  die 
Uebertragung  mancher  der  mit  der  Cerebrospinalflussigkeit  in  Verbindung 
gebrachten  Droguen  ist  manchmal  von  entschiedenem  Werte,  aber  immer 
erst  in  zweiter  Linie  gegeniiber  dem  oben  Erwahnten.  Die  Untersuchung 
sollte  so  vollstandig  sein,  als  die  Umstande  und  die  verwertbare  Menge  des 
Specimens  es  erlauben. 

Die  hauptsachlichen  diagnostischen  und  Differenzirungspunkte  sind 
folgende:  In  tuberkuloser  Meningitis  ist  der  Druck  der  Cerebrospinal- 
fliissigkeit vermehrt;  der  Anblick  meistens  durchsichtig  und  farblos, 
gelegentlich  leicht  opalisirend.  Die  Dichtigkeit  ist  nicht  sehr  vermehrt; 
das  Eiweissgewicht  ist  zwischen  dreiviertel  und  zwei  auf  tausend,  das 
Gerinnsel  diinn  und  schwach.  Sediment  schwach.  Zellzahlung:  Durch- 
schnittszahl  der  Lymphocyten  86%.  Bacteriologie:  Tuberkelbazillen  an- 
wesend  in  88%  der  Falle. 

Wenn  Tuberkelbazillen  anwesend  sind,  so  mag  ein  relatives  Anwachsen 
von  polynuclearen  Zellen  eine  Mischinfection  andeuten.  Bei  Abwesenheit 
von  Bazillen  und  wenn  Lymphocyten  iiberwiegen,  sollte  die  Suche  wieder- 


DIAGNOSTIC   PUNCTURE   IN   ACUTE   MENINGITIS. — SONDERN,  597 

holt  und  die  Moglichkeit  einer  Pseudo meningitis  von  Pneumonie  oder 
Typhus  in  Erwagung  gezogen  werden.  Eitrige  Specimene  geben  f iir  gewohn- 
Hch  keine  Schwierigkeiten  fiir  die  Diagnose.  Die  relative  Vermehrung  der 
polynuclearen  Zellen  und  die  meist  nicht  wechselnde  Gegenwart  von  intra- 
cellularen  Diplokokken  unterscheiden  Falle  von  cerebrospinaler  Meningitis. 


DISCUSSION. 

Dr.  E.  Libman  (New  York) :  At  the  Mount  Sinai  Hospital  in  New  York 
city  we  have  examined  over  900  cerebrospinal  fluids.  The  work  on  the 
fluids  from  tuberculous  cases  was  done  mainly  by  Dr.  E.  P.  Bernstein.* 
The  cases  reported  by  Dr.  Koplik  and  referred  to  by  Dr.  Sondern  were 
nearly  all  studied  by  Dr.  Bernstein.  In  his  first  investigation  he  found  the 
bacilh  during  hfe  in  over  94  per  cent,  of  the  cases.  In  the  last  one  hundred 
cases  he  found  the  bacilli  every  time.  He  spreads  the  coagulum,  if  there  be 
one,  and  the  sediment  on  one  cover-glass.  Patience  on  the  part  of  the 
investigator  is  of  great  importance  in  searching  for  the  bacilli.  In  Dr. 
Bernstein's  paper  the  percentages  of  polynuclear  cells  and  lympocytes  found 
in  the  various  fluids  are  detailed. 

In  so-called  meningismus  we  have  also  occasionally  found  a  lymphocy- 
tosis; but,  in  that  form  complicating  mastoid  disease,  there  may  be  a  poly- 
nucleosis.    Dr.  Rist  tells  me  he  has  had  similar  experiences. 

The  fluid  in  tuberculous  meningitis  may  have  a  yellowish  tinge.  Tliis 
can  occur  in  other  conditions.  The  copper-salt  reducing  substances  may 
be  present  (rarely)  in  tuberculous  meningitis.  Its  absence  speaks  against 
a  serous  meningitis.  It  is  of  value  to  determine  the  pressure,  especially  in 
doubtful  cases;  for,  in  cases  of  tumor  in  the  posterior  fossa  (which  may 
resemble  tuberculous  meningitis),  death  may  occur  after  puncture.  In 
these  cases  there  is  a  rapid  drop  in  pressure  after  the  removal  of  a  small 
amount  of  fluid.  This  may  be  regarded  as  a  warning  to  withdraw  no  more 
fluid. 

*  Reported  in  Mount  Sinai  Hospital  reprints,  vol.  v 


AN  EXPEDITIOUS  METHOD  FOR  THE  DETECTION  OF 
TUBERCULOSIS  AMONG  SCHOOL-CHILDREN. 

By  C.  Harlan  Shoemaker, 

Philadelphia. 


The  method  set  forth  in  this  paper  will  not  only  detect  those  children  in 
poor  health  in  the  schools,  whose  general  welfare  is  a  matter  of  public  con- 
cern, but  will  be  as  applicable  to  any  large  body  of  individuals,  whether  in 
stores  or  in  shops,  as  to  school-children. 

Fortunate,  indeed,  is  the  medical  inspector  of  schools  whose  work  is 
confined  to  the  inspection  of  5000  children,  without  the  interruption  conse- 
quent upon  his  withdrawal  for  other  sanitary  work.  This  relation  time  to 
work  allotted  is  very  important  in  the  elimination  of  any  disease  or  in  the  cor- 
rection of  defects.  Hence  the  necessity  for  such  assistance  as  can  be  depended 
upon  for  the  segregation  of  the  suspiciously  ill,  the  sick,  and  the  defectives. 
It  seems  to  me  a  great  waste  of  time  for  a  medical  inspector  to  test  the 
vision  by  Snellen's  test-types.  In  fact  these  statistics  should  be  tabulated 
and  handed  to  him  three  hours  after  school  is  convened.  Preliminary 
examination  should  and  could  be  made  by  each  individual  teacher  of  her 
class  at  least  twice  a  year,  thus  sorting  out  for  the  medical  inspector  a  suffi- 
cient number  of  children  to  occupy  his  entire  time.  Furthermore,  it  will 
be  the  first  step  toward  substituting  results  for  statistics.  We  should  not 
be  interested  in  healthy  children,  nor  allow  them  to  consume  so  much  of 
our  attention,  so  long  as  the  suspiciously  ill,  the  sick,  or  the  defective  child 
remains  untreated. 

The  relative  importance  of  spending  the  inspector's  time  percussing  lungs, 
and  overcoming  parental  objections,  in  order  that  1  per  cent,  of  tuberculous 
children  may  be  detected,  as  compared  with  the  importance  of  relieving 
60  per  cent,  of  the  children  of  physical  defects,  is  exaggerated,  because  from 
8  to  12  per  cent,  of  the  tonsils  and  adenoids  removed  are  found  to  be  tuber- 
culous, so  that  even  the  detection  of  these  defectives  is  a  wise  public  policy. 
I  doubt  if  we  can  ever  make  the  children  physically  perfect  before  their  educa- 
tion is  begun  by  the  State,  but  that  privilege  should  certainly  be  understood 
as  granted  when  the  education  is  begun.  Whatever  benefits  the  child,  must 
ultimately  benefit  the  State. 

Let  us  imagine,  if  we  can,  that  1  per  cent,  of  the  school-children  are 

598 


RAPID  DETECTION  OF  TUBERCULOUS  SCHOOL-CHILDREN. — SHOEMAKER.     599 

tuberculous;  also  that  a  skilled  diagnostician  should  have  5000  under  liis 
control,  and,  at  the  end  of  the  semester,  he  will  have  examined  500  chests 
and  found  5  cliildren  afflicted;  he  has  then  'allowed  4500  children  not  ex- 
amined in  any  way,  of  whom  45  may  be  said  also  to  be  tuberculous,  to  pass 
an  entire  term  together. 

I  do  not  believe  that  an  inspector  should  interest  himself  in  the  exact 
location  of  a  lung  cavity,  any  more  than  in  the  exact  etiology  of  the  con- 
tagious eye  diseases  that  come  under  his  observation.  The  first  object  of 
an  inspector  is  to  locate  all  suspicious  cases  of  contagious  disease.  The 
second  object  should  be  to  have  all  doubtful  diagnoses  confirmed  by  an 
expert.  And,  what  might  be  called  his  third  object,  is  the  return  of  the 
child  to  school  cured.  The  last  duty  he  should  be  relieved  of,  because  it 
greatly  complicates  his  work. 

We  most  probably  shall  not  entirely  control  the  school  problem  of  tuber- 
culosis unless  dispensaries  are  established  under  the  departmental  juris- 
diction. In  this  way  only  can  an  official  record  be  kept.  The  fallibility  of 
fever,  cough,  rales,  and  the  like,  as  means  of  establishing  an  absolute  diagnosis 
in  cliildren,  is  generally  conceded.  Even  in  the  late  stages  the  absence  of 
expectoration  is  usual  in  children.  The  presence  of  tubercle  bacilli  in  the 
feces  seem  to  be  a  very  reasonable  diagnostic  point.  Nearly  all  cliildren 
that  I  have  seen  swallow  their  sputum. 

In  Philadelphia,  from  five  to  seven  very  evident  and  most  probably 
contagious  cases  of  tuberculosis  have  been  reported  each  year  of  medical 
inspection.  There  were  159,217  children  on  the  school  register  for  the  year 
1906.  Of  these,  8  children  were  reported  by  the  medical  inspector  as  being 
evidently  tuberculous. 

The  division  of  vital  statistics  reports,  during  the  year,  the  following 
deaths  from  tuberculosis: 


Under 
1. 

1 

TO  2. 

2 

TO  5. 

5 

TO  10. 

10 
TO  15. 

15 
TO  20. 

Boys. 

Girls. 

LunfiTS           

49 
56 

7 

4 
2 

27 

42 

2 

3 

2 

31 
53 

7 

1 

1 

1 

30 

28 

3 

3 

1 

47 

10 

4 

2 

2 

309 

7 

13 

2 

6 

209 
109 
16 
6 
2 
9 
3 
1 

284 

87 

Abdorninal 

20 

Pott's     

2 

White  swelling 

Tuberculosis  of  other  organs . . . 
General                           

5 
2 

Scrofula  

— 

Totals 

118 

76 

94 

65 

65 

337 

355 

400 

The  estimated  population  of  the  city  of  Philadelphia  is  1,500,395.     There 
were  more  deaths  among  infants  than  in  any  other  age  period  excepting 


600  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

that  of  from  fifteen  to  twenty  years.  Nevertheless  the  infant  mortaUty 
has  fallen  10  per  cent,  in  twenty-seven  years.  The  infant  mortality  from 
tuberculosis  is  0.07  per  cent,  of  the  total  population.  We  cannot  get  a 
percentage  of  mortality  at  age  periods  in  America  except  during  a  census 
year,  so  that  accurate  comparison  of  American  and  foreign  statistics  is  im- 
possible. Disregarding  the  infant  mortality  for  the  moment,  the  death-rate 
from  two  to  five,  a  period  of  three  years,  is  higher  than  that  of  from  five  to 
ten  or  ten  to  fifteen  years.  This  ratio  is  different  from  foreign  statistics, 
w^here  the  gi-eatest  vulnerability  to  tuberculosis  in  children  is  shown  to  be 
just  before  and  during  pubescence. 

There  is  a  rather  wide  discrepancy  between  130  deaths  from  tuberculosis 
among  children  of  the  compulsory  school  age — that  is,  from  five  to  fifteen 
years  (according  to  Philadelphia  law,  eight  to  fourteen) — and  the  actual 
report  of  8  cases.  From  a  series  of  cases  reported  by  Cronin,  of  New  York, 
last  year,  only  10  out  of  the  number  were  possibly  tuberculous.  No  doubt 
the  discrepancy  between  the  death-rate  and  the  morbidity  rate,  per  age 
period,  is  the  same  in  New  York  as  in  Philadelphia.  If  we  suppose  that  the 
medical  inspector  has  not  overlooked  any  tuberculous  children  under  his 
care,  then  but  one  solution  offers  itself  to  account  for  this  difference  between 
the  mortality  and  morbidity  rate  at  the  compulsory  school  age,  and  that  is 
the  voluntary  withdrawal  of  the  sick  before  they  reach  the  stage  in  which 
the  disease  can  be  detected  at  a  glance  without  the  removal  of  the  clothing. 
Experience,  however,  teaches  me  that  the  same  rule  holds  good  among 
adults— this  voluntary  withdrawal  of  the  sick  from  the  large  factory  to  the 
small  shop,  and  from  the  latter  to  home  work,  so  it  is  fair  to  suppose  that  a 
sick  child  might  be  humored. 

Our  inability  to  reach  conclusions,  through  the  examination  of  all  the 
children  from  houses  occupied  by  tuberculous  families,  is  hindered  by  the 
vast  number  of  normal  children  that  must  be  examined  in  order  that  very 
few  afflicted  children  may  be  detected.  The  difficulty  of  appl3dng  the  fore- 
going rule  may  further  be  illustrated  by  the  overwhelming  number  of  cliil- 
dren  who  would  have  to  be  examined  if  all  the  children  from  infected  homes 
in  the  fifth  ward  were  selected.  The  Phipps  Institute  occupies  almost  the 
geographical  center  of  the  ward,  which  comprises  35  city  squares,  with  a 
total  population  of  17,130,  or  83.3  persons  per  acre.  The  death-rate  in  this 
ward,  exclusive  of  the  Phipps  Institute,  is  61.3  per  10,000,  or  at  least  twice 
that  of  any  other  ward,  and  three  times  what  it  was  before  the  Phipps  In- 
stitute located  there.  It  is  evident,  from  the  mortality  report  alone,  that  an 
inspector  could  never  approach  his  routine  school  work  in  this  neighborhood. 
The  fact  that  a  few  consumptives  escape  being  reported  would  lead  to  the 
oversight,  perhaps,  of  the  very  children  who  need  the  examination  most. 
But  the  converse  view  of  this  house  rule,  the  inspection  of  the  dwellings  of 


RAPID  DETECTION  OF  TUBERCULOUS  SCHOOL-CHILDREN. — SHOEMAKER.    601 

tuberculous  children,  would  work  admirably  among  consumptives,  young 
or  old. 

Knopf  stated  last  year  that  tuberculosis  cannot  be  eradicated  if  we  do 
not  begin  with  the  child.  This  reinforces  my  assertion  that  it  would  be 
more  practical  to  investigate  the  homes  of  children  found  to  be  tuberculosis 
suspects,  or  actually  afflicted  with  the  disease,  in  order  that  we  might 
ascertain  who  infected  the  child  and  invent  means  to  restrict  further  dis- 
semination. 

The  folloT^dng  method  for  the  continuous  observation  of  this  disseminat- 
ing focus  of  the  tubercle  bacilli  without  discomfort  to  the  public  or  patient 
is  suggested:  After  the  usual  notification  of  a  patient  suffering  mth  tuber- 
culosis has  been  received,  it  should  be  placarded  upon  a  verj^  accurate  map 
before  it  is  filed  away  in  the  card  catalogue.  A  conveyancer's  map,  such  as 
gives  the  lot  frontage,  character  of  dwelling,  drainage,  etc.,  will  answer  the 
purpose  admirably.     A  sticker  bearing  the  date,  stage  of  disease,  and  the 

8-23-08 
patient's  initials        2      is  to  be  placed  upon  this  dwelling. 
S.  R. 

It  can  then  be  forgotten  until  subsequent  reports  draw  attention  to  it. 
A  vigilant  Bureau  of  Health  will  draw  at  least  four  notifications  on  each 
patient  as  his  end  draws  near,  for  at  least  one-half  of  the  physicians  in 
attendance  will  report  the  case.  If,  hoM^ever,  these  reports  should  show 
several  families  infected  in  the  same  dwelling  year  after  year,  drastic  action 
could  be  well  aimed.  Reports  card-catalogued  make  good  statistics, 
whereas  those  charted  are  vital. 

Very  little,  and  that  chiefly  of  an  educational  nature,  is  done  for  the 
individual  harboring  the  tubercle  bacilli.  Excepting  for  the  Pliiladelphia 
hospital  and  a  few  beds  in  one  or  two  other  institutions,  the  advanced  con- 
tagious case  cannot  secure  isolation. 

The  necessity  of  a  rapid  method  for  the  detection  of  incipient  cases  of 
tuberculosis,  so  that  teachers  and  shop  foremen  may  have  some  point  of 
observation  to  confirm  their  suspicions,  is  apparent.  We  will  never  have  a 
sufficient  number  of  inspectors  to  fill  these  places.  The  people  must  be 
educated  to  do  the  grosser  part  of  the  work,  and  they  must  have  some 
tangible  basis  upon  which  to  work. 

The  teacher  with  a  broader  humanitarian  outlook  may  be  taught  to 
watch  her  charges,  whereas  the  shop  foreman,  urged  on  by  an  anxious 
employer,  could  be  aroused  to  do  his  full  duty  by  obtaining  a  certificate  of 
health  for  doubtful  cases.  The  employer's  anxiety  could  be  aroused  by  a 
well-ordered  liability  law,  similar  to  the  English  law,  which  would  necessi- 
tate the  insurance  of  all  help  in  his  employ.    Doubtless  he  would  see  that  all 


602  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

employees  were  declared  to  be  healthy,  and  surely  free  from  tuberculosis, 
before  he  employed  them. 

The  best  method  for  separating  the  robust  eliild  from  the  delicate  one 
that  can  be  put  into  the  hands  of  the  laity  is  by  means  of  a  torsion  balance. 
Let  us  weigh  our  cliildren  monthly.  At  the  end  of  the  second  month,  those 
who  had  lost  the  most  weight  should  be  sent  to  the  inspector.  In  due  time 
another  weighing  would  send  down  another  class.  At  first  the  lack  of 
interest,  change  of  clothes,  and  the  desire  to  fake  weight  would  cause  an 
amount  of  uncertainty,  but  as  the  innovation  wore  off  and  the  value  of  the 
method  for  the  determination  of  sick  and  well  proved  itself,  tliis  element 
would  entirely  disappear.  There  is  no  clinical  sign  so  reliable  or  so  expedi- 
tiously ascertained  as  the  body  weight.  All  healthy  children  gain  in  weight. 
This  fact  relieves  us  of  the  necessity  of  taking  the  height,  which  is  a  very 
important  point  when  dealing  with  adults.  The  report  of  the  examination 
by  the  inspector,  of  those  who  lose  or  remain  stationary  in  weight,  can  be 
confirmed  by  the  more  complete  examination  of  an  expert,  and  may  be  fol- 
lowed by  an  inspection  of  the  family  and  dwelling  if  the  child  is  proved  to 
be  tuberculous.  What  we  should  expect  to  find  among  those  children  losing 
weight  would  be,  in  all,  poor  nourishment,  especially  among  those  who  come 
to  school  without  breakfast,  and  children  attacked  by  infectious  or  con- 
tagious diseases. 

We  want  to  eliminate  from  our  examinations  all  apparently  healthy 
children  and  the  necessity  for  handling  them.  This  latter  is  the  point  of 
contention  among  parents.  Seldom,  if  ever,  do  parents  object  to  attention 
paid  to  a  sick  child,  but  they  rise,  wrathful,  at  our  approach  to  a  healthy  one. 

Conclusions:  I.  The  determination  of  the  loss  of  weight  in  the  incipient 
tuberculous  child  is  more  easily  made  than  any  method  heretofore  proposed 
for  the  examination  of  children  from  houses  where  tuberculosis  exists — and 
it  reaches  all  the  children. 

II.  The  determination  of  the  loss  of  weight  is  easier  and  of  greater  clini- 
cal importance  than  vague  physical  signs.  It  has  the  advantage  of  being 
applicable  to  every  child,  and  it  does  not  necessitate  unnecessary  handling. 

III.  A  torsion  balance  showing  fluctuation  in  the  body  weight  of  a  child, 
distinguishes  those  that  are  healthy  from  those  that  are  sick.  This  rapid 
discrimination  between  the  two  classes  of  children  is  necessary  in  order  to 
save  time. 


EIN  RESOLUTIONSVORSCHLAG. 

Von  Dr.  Adolf  Baumel, 

Eger. 


Die  Sektion  IV  des  diesjahrigen  Kongresses  soil  sich  mit  der  Bekamp- 
fung  der  Tuberkulose  bei  Kindern  beschaftigen ;  konnte  sie  dies  mit  einiger 
Griiiidlichkeit  tun,  so  ware  der  bose  Feind  nach  einiger  Zeit  aus  der  Welt 
geschafft,  aber  Wollen  und  Konnen  halten  nicht  gleichen  Sehritt  miteinander 
und  da  wird  es  notwendig  sein,  ausser  den  zweckmassigsten  Massregeln  auch 
die  durchfiilirbarsten  herauszusuchen.  Ich  glaube  nichts  Undurchfiihr- 
bares  zu  verlangen,  wenn  ich  beantrage,  der  Kongress  moge  die  folgende 
Resolution  beschliessen  und  den  Regierungen  aller  civilisierten  Lander  des 
Erdenrundes, — nicht  nur  jener,  die  auf  dem  Kongresse  vertreten  sind, — 
zur  ehesten  Durchfiihi'ung  empfehlen: 

Der  Kongress  halt  als  vorlaufigen  Sehritt  zur  griindlichen  Bekampfung 
und  Ausrottung  der  Tuberkulose  fiir  notwendig: 

1.  Dass  in  alien  Anstalten,  in  denen  Kinder  zu  Ueberwachungs-  und 
Unterrichtszwecken  dauernd  oder  fiir  langere  Zeit  untergebracht  sind  (Wai- 
senhauser,  Kindergarten,  Kleinkinderbewahranstalten,  Schulen),  die  An- 
staltserhalter  dazu  verpflichtet  werden,  die  Zoglinge  in  regelmassigen  Zwi- 
schenraumen,  mindestens  aber  zweimal  in  jedem  Jahre  einer  griindlichen 
arztlichen  Untersuehung  unterziehen  zu  lassen. 

2.  Dass  iiber  das  Resultat  dieser  Untersuchungen  nicht  nur  nach  gleichen 
Grundsatzen  zu  verfassende  Listen  gefiihrt,  sondern  auch  fiir  jedes  einzelne 
Kind  als  Auszug  dieser  Liste  ein  Gesundheitszettel  verfasst  werde,  der  bei 
Uebergang  in  eine  andere  Lehranstalt  dieser  zu  iibergeben,  bei  Abschluss 
der  Unterrichtszeit  aber  auf  Wunsch  dem  gewesenen  Schiiler  einzuhandigen 
ware. 

3.  Dass  die  Anstalts(Schuler)halter  gesetzlich  berechtigt  und  verpflich- 
tet werden,  in  alien  jenen  Fallen,  wo  bei  einem  Kinde  Zeichen  von  manifester 
oder  latenter  Tuberkulose  oder  Vorkrankheiten,  die  erfahrungsgemass  zu 
tuberkulosen  Erkrankungen  fiihren,  festgestellt  werden,  eine  zweckent- 
sprechende  Behandlung  dieser  Kinder  einzuleiten,  wenn  nicht  die  Elter  nodcr 
sonstigen  Angehorigen  der  Kinder  den  Nachweis  erbringcn,  dass  dieses  von 
ihrer  Seite  aus  geschieht. 

603 


604  sixth  international  congress  on  tuberculosis. 

Begrundung: 

ad  1.)  Es  braucht  den  Teilnehmern  an  diesem  Kongresse  nicht  erst 
gesagt  zu  werden,  dass  in  den  meisten  Fallen  von  Tuberkulose — wenn  nicht 
in  alien — der  Beginn  der  Erkrankung  in  die  ersten  Lebensjahre  fallt  und  dass, 
je  eher  die  ersten,  unscheinbaren  Symptome  der  Krankheit  konstatiert  und 
in  Behandlung  genommen  werden,  desto  eher  auch  Aussicht  darauf  ist, 
dass  das  Uebel  dauernd  oder  doch  flir  langere  Zeit  zum  Stillstand  gebracht 
werde.  Es  ist  selbstverstandlich,  dass  es  am  rationellsten  ware,  die  Kinder 
von  der  Geburt  an  zu  iiberwachen,  die  Erkrankten  sofort  zu  behandeln 
und  so  vor  den  Fortschritten  der  Erkrankung  zu  bewahren;  ebenso  klar  ist 
es  aber,  dass  sich  dieser  Art  des  Vorgehens  weit  grossere  Schwierigkeiten 
entgegenstellen  wlirden,  als  der  vorgeschlagenen,  so  dass  sie  vorlaufig  als 
nicht  durchfiilii-bar  bezeichnet  werden  muss. 

Sind  aber  erst  die  Kinder  seitens  der  Eltern  einer  Erziehungs-  oder 
Unterrichtsanstalt,  sei  es  ganz,  sei  es  f iir  mehrere  Stunden  taglich,  anvertraut, 
dann  kann  das  Gemeinwesen  geltend  machen,  dass  jedes  einzelne  Kind, 
das  erkrankt,  fiir  die  anderen  eine  Gefahr  bildet  und  kann  fiir  sich  in  An- 
spruch  nehmen,  sich  durch  seine  Organe  davon  zu  iiberzeugen,  welche  Kinder 
gesund  und  welche  dies  (im  weitesten  Sinne)  nicht  sind,  kann  aber  auch 
verlangen,  dass  bloss  solche  am  Unterrichte  teilnehmen,  die  fiir  die  iibrigen 
nach  keiner  Richtung  eine  Gefahr  bilden,  auch  nicht  nach  der  gesundheit- 
lichen. 

In  vielen  Landern  bestehen  bis  zum  heutigen  Tage  schularztliche  Ein- 
richtungen  iiberhaupt  nicht;  in  anderen  sind  wohl  Aerzte  im  Nebenamte 
bestellt,  doch  kommen  sie  selten  dazu,  alle  Schiiler  regelmassig  und  griind- 
lich  zu  untersuchen  und  so  rechtzeitig  das  Auftreten  der  Tuberkulose  (und 
anderer  Krankheiten)  wahrzunehmen ;  wohl  an  den  allerwenigsten  Orten 
sind  die  Aerzte  in  der  Lage,  unabhangig  von  gewissen  Zufalligkeiten,  wie  sie 
die  Aufmerksamkeit  des  Lehrpersonals,  der  Stundenplane  u.  s.  w.  bedingen, 
ihr  praventives  Amt  auszuiiben.  Es  kann  dies  nur  dann  geschehen,  wenn 
Gesetzesnormen  geschaffen  werden,  die  die  Untersuchung  nicht  nur  gestatten, 
sondern  auch  obligatorisch  machen. 

Wenn  wir  nun  in  Betracht  ziehen,  dass  die  Tuberkulose  vorwiegend 
eine  Krankheit  der  Armen  insofern  ist,  als  bei  diesen  nach  jeder  Richtung 
ungiinstige  hygienische  Verbal tnisse  gegeben  sind,  wo  leichter  Familienin- 
fektion  in  engen,  schlecht  geliifteten  Wohnraumen  stattfindet,  wo  auf  die 
Sauberkeit  nicht  jene  Aufmerksamkeit  verwendet  werden  kann,  wie  bei 
besser  situierten  Leuten,  und  wo  die  Infektion,  wenn  sie  stattgefunden  hat, 
in  dem  Korper  des  schlechtgenahrten  Kindes  leichter  zur  Ausbreitung  ge- 
langt,  eventuell  auch  schon  friihzeitig  zu  Zerstorungen  fiihrt,  dann  leuchtet 
ohne  weiteres  ein,  dass  das  Aufsuchen  der  Ersterscheinungen  der  Krankheit 
sich  ausser  auf  die  Schulen  auch  auf  jene  Anstalten  erstrecken  muss,  wo 


EIN   RESOLUTIONSVORSCHLAG. — BAUMEL.  605 

hauptsachlich  die  Kinder  der  armen  Arbeiterbevolkerung  untergebracht 
werden,  wahrend  die  Eltern,  erwachsenen  Geschwister  u.  a.  dem  Erwerbe 
nachgehen  miissen;  das  sind  eben  die  Kindergarten  und  Kinderbewahran- 
stalten,  woraus  noch  der  Vorteil  erwachst,  dass  ein  Teil  der  Kinder  noch  vor 
dem  schulpfiichtigen  Alter  der  arztlichen  Ueberwachung  zugefiihrt  wird. 

ad  2.)  DieserPunktbedarfkaumeiner  naherenBegi-iindung.  Die  Listen 
werden  nicht  niir  als  Grundlage  zu  einer  reellen  Statistik  des  Kindesalters 
dienen  und  zeigen  konnen,  wie  gewisse  KJrankheiten  im  Laufe  der  Jahre  zu- 
oder  abnehmen,  oder  wde  sich  die  Gesamtentwicklung  in  einer  bestimmten 
Gegend  im  Laufe  der  Zeit  in  progressiver  oder  degenerativer  Richtung  an- 
dert  (Korperbau,  Gewicht,  Brustumfang,  etc.),  sie  werden  auch  insbesonders 
in  Form  des  Gesundheitszettels  (der  als  Kopie  der  Eingetragenen  in  die  Liste 
gedacht  ist),  ermoglichen,  eine  verlassliche  Anamnese  iiber  jedes  jugend- 
liche  Individuum  zu  erlangen,  und  es  ist  dies  von  hoher  Wichtigkeit  nicht 
nur  beim  Uebergange  von  einer  Erziehungs-  oder  Lehranstalt  in  die  andere, 
aber  auch  spaterhin  bei  der  Berufswahl,  wo  ja  ein  Missgriff  unter  anderen 
Schadlichkeiten  auch  die  Gefahr  mit  sich  bringt,  dass  z.  B.  ein  Individuum, 
welches  bei  landlicher  Arbeit  sehr  wohl  gesunden  und  erstarken  konnte, 
in  einen  gewerblichen  Betrieb  kommt,  der  demselben  den  sicheren  Ruin 
bedeutet. 

ad  3.)  Am  notwendigsten  erscheint,  dass  das  Prinzip  der  Zwangsbe- 
handlung  gesetzHch  festgelegt  werde.  Wenngleich  zweifellos  ist,  dass  um  so 
bessere  Aussichten  f  iir  die  vollkommene  Ausheilung  der  Tuberkulose  vorhan- 
den  sind  und  dass  dies  mit  um  so  geringerer  Storung  des  Fortganges  der 
Arbeit  (UnteiTichtes)  erfolgen  kann,  je  eher  d.  i.  in  einem  je  friiheren  Sta- 
dium der  Krankheit  an  die  Behandlung  der  Leidenden  oder  Gefahrdeten 
geschritten  ^^ird,  so  ist  es  doch  schwer,  meistens  sogar  unmoglich,  die  Kran- 
ken  oder  deren  Umgebung  davon  zu  iiberzeugen,  dass  dieses  oder  jenes  Kind, 
das  scheinbar  ganz  gesund  ist,  nicht  hustet,  nicht  fiebert,  doch  schon  An- 
fangserscheinungen  von  Tuberkulose  bietet,  die  der  Behandlung  bediirfen, 
wenn  nicht  der  Prozess  fortschreiten  soil,  um  dann  immer  sehwerer  heilbar 
zu  sein.  Selbst  wenn  sonst  scheinbar  ganz  verniinftige  erwachsene  Leute 
wegen  Initialerscheinungen  arztliche  Hilfe  in  Anspruch  nehmen,  so  geschieht 
dies  in  den  allermeisten  Fallen  nicht  langer,  als  bis  jene  Symptome,  die 
ihnen  selbst  aufgef alien  sind,  und  die  sie  zum  Arzte  gefiihrt  haben,  wieder 
geschwunden  sind;  verlangt  aber  der  Arzt  eine  Fortsetzung  der  Behandlung 
oder  der  Beobachtung,  so  sehen  sie  in  diesem  Begehren  eine  allzu  grosse 
Aengsthchkeit  wenn  nicht  gar  minder  lautere  Motive  ihres  Beraters.  Und 
wie  oft  schrecken  die  Kosten  der  Behandlung  von  der  Vornahme  einer  solchen 
ab !  Die  Oeffenthchkeit  hat  die  moralische  Verpflichtung,  in  solchen  Fallen 
helfend  einzugreifen,  liingst  anerkannt,  indem  sie  auf  dem  Wege  der  Privat- 
wohltatigkeit    Institutionen  schuf,  die  den  minder    Bemittelten  zu  gute 


606  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

kommen  sollten;  die  Gemeinwesen  (Stadte,  Lander,  Staaten)  sind  nachge- 
folgt;  aber  so  loblich  und  in  einzelnen  Fallen  niitzbringend  auch  diese  Insti- 
tutionen  waren  und  sind,  sie  kamen  und  kommen  nur  immer  einer  gerin- 
geren  oder  grosseren,  immer  aber  beschrankten  Anzahl  Hilfsbediirf tiger  zu 
gute  und  an  die  Wurzel  des  Uebels  reichen  sie  so  lange  nicht,  als  nicht  alle 
Erkrankten  in  friihestem  Stadium  ermittelt  und  alle  behandelt  werden, 
bevor  sie  schwer  heilbar  oder  unheilbar  geworden  und  bevor  sie  Infektions- 
quellen  fiir  andere  sind. 

Eben  der  Umstand  aber,  dass  jeder  offen  tuberkulose  Mensch  eine  Gef ahr 
fiir  eine  nicht  niiher  zu  bestimmende  Anzahl  anderer  Individuen  bildet, 
gibt  auch  der  Allgemeinheit  das  moralische  Recht,  aus  offentlichen  Riick- 
sichten  jeden  Tuberkulosen  durch  die  Behandlung  unschadhch  (und  dabei 
gesund)  zu  machen,  ebenso  wie  es  bei  Cholera-,  Pocken-,  Pest-  und  an- 
dern  Kranken  durch  Isolierung  und  Behandlung  geschieht,  und  wenn  das 
Recht  hierzu  gesetzlich  statuiert  wird,  so  ist  das  ein  Anfangsschritt  zu  einer 
radikalen  und  grossziigigen  SanitatspoUtik,  die  um  so  segensreicher  ware, 
auf  ein  je  grosseres  Gebiet  der  kultivierten  Erde  sie  sich  erstrecken  wiirde. 

Ein  Hindernis  in  der  Durchfiihrung  der  vorgeschlagenen  Grundsatze 
ware  wohl  in  deren  Kosten  gelegen,  doch  gewiss  kein  uniiberwindliches;  denn 
abgesehen  davon,  dass  es  wohl  kaum  rentablere  Staatsausgaben  geben  kann, 
als  solche,  durch  die  dem  Gemeinwesen  und  der  Volkswirtschaft  tausende 
von  Arbeitskraften  erhalten,  zum  mindesten  aber  fiir  viele  Jahre  in  ihrer 
Leistungsfahigkeit  erhoht  werden,  wiiren  die  Kosten  bei  dem  angegebenen 
Vorgehen  gar  nicht  so  ausserordentlich  hohe  und  konnten  manche  Betrage, 
die  jetzt  als  Zuschiisse  fiir  die  Unterbringung  bereits  ernstlich  Erkrankter 
geliefert  werden  miissen,  hier  verwendet  werden,  um  jene  Erkrankungen 
zu  vermeiden. 


Compulsory    Examination    and    Treatment   in  Nurseries,   Schools, 
Orphan  Asylimis,  etc. — (Baumel.) 

In  most  cases,  tuberculosis  begins  in  the  first  year  of  life. 
Recommendations : 

1.  Thorough  medical  examination  at  least  twice  a  year  in  orphan 
asylums,  kindergartens,  nurseries,  and  schools. 

2.  Uniform  reports  and  certificates  to  be  transmitted  to  other  institu- 
tions to  which  the  child  will  go  or  to  be  handed  to  the  child  after  the 
end  of  the  school  year. 

3.  Unless  the  parents  have  done  so,  the  institutions  for  the  treat- 
ment of  general  or  local  tuberculosis,  or  such  diseases  as  lead  to  tuber- 
culosis, must  care  for  these  cases. 


EIN   RESOLUTIONSVORSCHLAG. — BAUMEL.  607 

Examen  Obligatorio  en  los  Planteles,  Escuelas,  Asilos  de  Huerfanos,  Etc. 

— (Baumel.) 

Las  mas  veces  la  tuberculosis  empieza  en  los  primeros  anos  de  vida. 
Recomendacion : 

1.  Examen  medico  completo  6  lo  menos  dos  veces  al  ano  de  los  asilos  de 
huerfanos,  "kindergarten,"  planteles  y  escuelas. 

2.  Informenes  uniformes  y  certificados,  los  cuales  seran  transmitidos  a 
las  otras  instituciones  donde  va  el  nirio,  6  estos  deberan  ser  entregados  al 
nino  al  fin  del  ano  escolar. 

3.  Salvo  el  caso  que  los  padres  lo  hayan  hecho,  la  institucion  debera 
cuidar  del  tratamiento  de  la  tuberculosis,  manifestada  6  local,  6  de  ciertas 
enfermedades  predisponentes  a  la  tuberculosis. 


Examen  obligatoire  dans  les  creches,  €coles,  torphelinats,  etc. — (Baumel.) 
Dans  la  plupart  des  cas  la  tuberculose  commence  dans  la  premiere  annee 

de  la  vie. 

Recommandations : 

1.  Examen  medical  attentif  au  moins  deux  fois  par  an  dans  les  orphelinats, 
les  Kindergartens,  les  creches  et  les  ecoles. 

2.  Rapports  et  certificats  uniformes  que  Ton  transmettra  aux  autres 
institutions  ou  I'enfant  ira,  ou  que  I'on  remettra  k  I'enf ant  a  la  fin  de  Tann^e 
scolaire. 

3.  A  moins  que  les  parents  ne  I'aient  fait  eux-memes,  les  institutions  doi- 
vent  pourvoir  au  traitement  de  la  tuberculose  manifeste  ou  locale  et  des 
maladies  qui  menent  k  la  tuberculose. 


SECTION  IV. 

Tuberculosis  in  Children — Etiology,  Prevention,  and 
Treatment  [Continued), 


FOURTH  DAY.     AFTERNOON  SESSION. 

Thursday,  October  1,  1908. 

HYGIENIC  AND  CLIMATIC   PROPHYLAXIS.     CARE   OF   THE   CHIL- 
DREN OF  CONSUMPTIVES. 


The  President,  Dr.  Jacobi,  called  the  Section  to  order  at  three  o'clock. 


THE  VALUE  OF  CHILDREN'S  GARDENS  IN  CONGESTED 

NEIGHBORHOODS  FOR  THOSE  CHILDREN  WITH 

A  TENDENCY  TO  TUBERCULOSIS  OR  FOR 

THOSE   IN  WHOM  THE  DISEASE  HAS 

BEEN  ARRESTED  OR  CURED. 

By  Mrs.  Henry  G.  Parsons, 

New  York  City. 


There  is  no  difference  of  opinion  among  physicians  to-day  as  to  the  neces- 
sity of  open-air  living  for  children  having  a  tendency  toward  tuberculosis, 
for  those  in  whom  the  disease  has  been  arrested  or  cured,  or  for  the  preserva- 
tion of  the  health  of  those  in  whom  no  disease  exists.  Not  more  than  1  in 
500  can  be  accommodated  at  the  seaside  and  mountain  homes,  and,  besides, 
the  sea  air  does  not  agree  with  all  children.  Moreover,  it  is  neither  possible 
nor  right  for  any  large  number  of  children  to  be  separated  from  parental  care. 
Therefore,  we  must  provide  open-air  spaces,  near  their  homes,  where  children 
can  spend  the  whole  day,  if  necessary,  without  anxiety  to  their  parents. 

We  cannot  leave  the  matter  of  health  and  education  entirely  in  the  hands 
of  the  scientist — ^we  need  him,  but  he  also  needs  us  to  make  the  results  of  his 
research  and  discoveries  practical  utilities.  After  making  a  close  study 
for  years  of  churches,  schools,  settlements,  and  existing  organizations;  and 

608 


NEIGHBORHOOD    GARDENS   FOR    CHILDREN. — PARSONS.  609 

nowhere  finding  satisfaction  in  the  results  obtained  or  for  the  money  and 
labor  expended,  I  set  myself  about  to  find  the  flaw.  By  the  expression  on 
the  children's  faces  I  decided  that  they  were  living  under  conditions  that 
home,  school,  and  church  did  not  reach.  Most  elaborate  plans  were  laid 
out  for  the  physical  welfare  of  the  child,  but  only  in  few  instances  were  they 
carried  out  by  the  teacher.  As  I  sat  on  the  platform  at  the  opening  exercises 
of  the  schools,  watching  the  children  marching  to  their  seats,  not  one  in  a 
hundred  presented  an  appearance  that  would  lead  one  to  feel  that  they 
were  able  to  endure  the  five  hours  of  strain  before  them.  Through  my  in- 
timacy with  the  mothers  of  these  children  I  gathered  much  information  as 
to  the  causes  for  many  physical  defects  in  the  children;  for  example,  round 
shoulders  and  bent  backs  in  children  of  eight  or  ten  years  of  age.  At  nine 
in  the  morning,  after  a  refresliing  night's  sleep,  one  would  naturally  expect 
a  different  appearance.  I  found,  in  one  instance,  that  a  girl  of  ten  had  put 
a  half  a  ton  of  coal  into  the  cellar  the  night  before.  It  was  evident  that  some 
plan  must  be  worked  out  that  would  bring  about  all  these  corrective  pro- 
cesses in  a  natural  and  unavoidable  way,  and  I  decided  to  draw  a  group  of 
these  children  out  into  the  open,  with  no  other  influence  bearing  upon  them 
for  the  time  being  but  my  own. 

The  First  Children's  School  Farm  in  New  York  city  was  planned  with 
the  idea  of  putting  into  practical  operation  all  the  discoveries  that  our  best 
scientists  have  found  to  be  needed  for  the  building  up  of  strong  healthy 
bodies  and  minds  in  our  children,  and  to  fit  into  the  school  curriculum  a 
branch  that  would  unconsciously  bring  about  these  results  and  meet  the 
need  of  the  weak  and  the  strong. 

For  the  delicate  or  crippled  child  the  ordinary  playground  and  street  is 
prohibitive,  because  of  the  intense  activity  and  noise.  Instead  of  the  ordi- 
naiy  playground,  with  its  glare,  noise,  and  monotony  of  color,  picture  to 
your  mind  an  ordinaiy  city  lot  transformed  into  a  garden  of  beauty,  filled 
with  living  green  things,  where  the  children  can  come  and  go  at  their  pleasure, 
with  individual  plots  of  such  a  size  as  to  be  easily  within  the  hmitation  of 
their  strength,  so  that  work  never  becomes  labor.  Such  a  garden,  within 
easy  access  of  the  home,  affords  opportunity  for  the  mother  to  sit  with  her 
sewing,  accompanied  perhaps  by  several  younger  children,  while  her  con- 
valescing or  dehcate  child  grows  strong  and  ruddy,  gains  a  keen  appetite, 
and  sleeps  well  after  its  hours  spent  in  the  open. 

The  success  of  the  First  Children's  School  Farm  in  New  York  city,  situ- 
ated in  a  tenement  and  factory  district  at  54th  Street  and  Eleventh  Avenue, 
during  the  seven  years  of  its  existence,  has  been  so  great  that  parents  have 
either  come  to  us  and  begged  us  to  take  their  convalescent  or  delicate  children 
into  the  garden  or  else  have  thanked  us  for  the  strength  and  health  gained 
by  their  children  in  the  garden.    The  benefit  of  the  garden  to  the  mother 

VOL.  11—20 


610  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

with  a  new-born  infant,  so  often  prone,  at  such  a  time,  to  develop  tubercu- 
losis, and  whose  only  opportunity  to  obtain  fresh  air  has  been  to  sit  on  the 
curbstone  with  her  baby  in  her  lap  and  her  feet  in  the  gutter,  is  incalculable. 
While  the  rights  of  the  children  have  been  thoroughly  protected,  and  this 
garden  has  been  kept  a  veritable  "  children's  world,"  its  service  to  the  con- 
valescent mother  has  been  enormous.  The  strongest  Hnk  between  the  gar- 
den and  the  adult  has  been  our  little  4x8  foot  plot  of  flax.  Inside  or  outside 
of  the  fence  can  be  seen  a  group  of  well-to-do,  or  perhaps  utterly  discouraged, 
Irish  neighbors,  husband  and  wife's  faces  lighting  up  with  the  memories  of 
home.  They  tell  us  the  whole  histoiy  of  the  process,  from  soil  preparation, 
seed  planting,  to  the  spinning  and  the  woven  cloth,  and  a  link  of  confidence 
is  established  and  sunshine  is  spread  through  the  lives  of  thousands,  and, 
after  all,  it  is  the  sunshine  of  disposition,  the  happiness  of  laughter,  that  we 
need. 

In  laying  out  such  a  garden,  we  must  keep  several  things  in  mind:  The 
esthetic — the  necessity  of  filling  the  mind  with  pleasant  thoughts;  individual 
ownership  is  an  incentive  to  draw  them  to  and  hold  them  in  such  an  attrac- 
tive spot.  The  plan  of  lay-out  as  to  width  and  direction  of  paths  is  far  more 
important  than  one  would  at  first  realize.  In  the  delicate  or  crippled  child 
a  great  timidity  is  developed  because  of  his  physical  handicap.  He  is  con- 
stantly in  fear  of  being  injured  by  coUision  with  his  more  active  playmates. 
We  have  in  the  New  York  garden  over  150  crippled  children,  and  one  notices 
with  astonishment  how  their  activities  have  been  developed  because  of  the 
straight  long  paths,  which  give  them  a  feeling  of  protection.  Here  they  can 
run  at  will  mthout  danger  of  colliding  with  their  playmates.  A  little  fellow 
of  seven,  who  had  lost  his  leg  through  an  accident,  seemed  to  cover  the  dis- 
tance from  gate  to  summer-house  in  three  jumps.  I  met  him  one  day  with 
a  watering-can  filled  with  water  in  each  hand,  his  crutch  fastened  through 
a  loop  in  his  trousers  so  that  it  could  not  fall. 

Now  what  crime  have  we  been  committing  by  suppressing  the  muscular 
energy  crying  out  for  action  in  these  crippled  children?  If  any  of  you  have 
tried  to  rear  a  delicate  child,  you  will  know  that  there  is  danger  of  a  moral 
tuberculosis,  or  self-centered  interest,  spasms  of  violent  temper,  cowardice, 
because  of  the  lack  of  the  natural  outlet  in  which  the  healthy  child  works 
off  its  surplus  spirits.  We  also  know  that  the  intense  activities  indulged  in 
through  games,  swings,  bicycles,  tennis,  etc.,  are  very  apt,  by  their  exciting 
interest  and  exhilaration,  to  lead  the  participants  to  indulge  in  them  to  the 
point  of  exhaustion.  In  the  majority  of  our  playgrounds  apparatus  is 
placed  where  all  can  use  it — apparatus  that,  in  a  private  gymnasium,  they 
would  be  allowed  to  use  only  after  at  least  two  years  of  training.  The 
broken  arms  we  see,  but  the  rupture  and  strain  on  delicate  organs  we  know 
nothing  of  until,  later  in  life,  when  we  have  an  invalid  girl  or  l^oy. 

With  manual  work  this  rarely  occurs,  for  as  soon  as  the  children  become 


NEIGHBORHOOD    GARDENS   FOR   CHILDREN. — PARSONS.  611 

a  little  tired  they  stop.  A  children's  garden,  properly  conducted,  affords 
work,  leisure  time  to  lie  on  a  bench  and  dream — think  of  it,  dream  in  the 
midst  of  the  city!  There  is  the  watering;  the  wheeling  of  a  wheelbarrow, 
just  the  right  size,  filled  with  vegetables,  weeds,  or  perhaps  a  baby  brother 
or  sister  in  it;  the  catching  of  butterflies  and  the  mounting  of  them;  hunting 
for  the  bad  and  the  good  lady-bug;  the  simple  lessons  in  hygiene  taught  by 
covering  certain  plants  with  flower-pots,  or  the  cutting  out  of  one's  initials 
of  cardboard  and  pinning  them  to  a  leaf  to  show  the  effect  of  shutting  off 
the  sun's  rays;  the  delights  of  getting  vegetables  of  one's  own  growing, 
cooking  them  in  a  well-equipped  kitchen  connected  with  a  garden,  or  under 
a  mere  shelter  with  an  oil  stove;  the  whittling  of  cultivating  sticks;  the  paint- 
ing of  the  plot  sign;  not  only  the  individual  plot  ownership,  but  the  com- 
munity spirit  of  making  the  whole  garden  beautiful  by  its  well-kept  paths  and 
weedless  flower-beds;  the  delight  of  receiving  guests  of  high  or  low  estate; 
the  pride  of  keeping  shining  tools  because  it  is  our  garden — the  neighbor- 
hood's garden.  So  manual  training,  domestic  science,  physical  culture, 
nature  study,  social  economics  have  all  been  correlated  in  this  first  Children's 
School  Farm  in  New  York  city,  not  by  accident,  but  by  a  carefully  thought- 
out  plan. 

Such  a  garden  should  include  healthy  as  well  as  delicate  children,  so  as 
to  bring  about  a  self-forgetfulness.  In  our  garden  in  New  York  we  do  not 
allow  the  term  "crippled  children"  to  be  used;  they  are  our  visitors,  and  we 
must  extend  every  courtesy  to  them,  and  the  healthy  little  farmers  vie  with 
each  other  in  taking  their  helpless  little  guests  about  the  garden  in  wheel- 
barrows, or  assisting  them  in  carrying  water  and  weeding  their  plots — so  the 
influence  is  retroactive.  These  children  are  brought  by  the  Crippled  Chil- 
dren's Driving  Fund  from  all  parts  of  New  York  city. 

No  park  in  a  congested  neighborhood  should  be  laid  out  without  consid- 
eration for  the  weak,  as  well  as  the  strong,  and  for  the  needs  of  all  ages,  from 
the  baby  to  the  grandfather.  Children's  gardens  should  be  placed  in  some 
parks,  but  not  in  all  parks;  on  some  lots  it  is  far  better  to  have  playgrounds 
than  gardens,  and  vice  versa.  Many  playgrounds  could  well  afford  to  spare 
some  space  for  a  garden. 

The  Children's  Garden  in  DeWitt  Clinton  Park  was  planned  also  to  show 
the  immense  value  to  be  derived  from  a  limited  space.  In  1902,  from  a 
space  118  x  84  feet  in  area,  accommodating  150  children,  the  garden  has 
grown  until  now,  in  1908,  it  occupies  a  space  250  x  135  feet  in  area,  accommo- 
dating 1100  children,  150  of  whom  are  cripples,  400  baby  brothers  and 
sisters,  500  parents  of  the  neighborhood,  and  1500  visitors;  besides  these,  30 
schools  use  the  garden  for  nature  study,  making  a  conservative  estimate 
of  about  3500  people  who  are  benefited  annually.  This  three-quarters  of 
an  acre  of  ground  affords  more  happiness  to  the  square  inch  and  is  more 
intensively  cultivated  than  any  piece  of  land  in  the  world. 


THE  OPEN-AIR  SCHOOL. 
By  Mrs.  Anna  Garlin  Spencer. 

New  York. 


The  subject  naturally  divides  itself  into  three  parts:  First,  the  open-air 
school  proper,  considered  as  an  essential  accompaniment  of  curative  agencies 
for  cliildren  and  youth  in  incipient  stages  of  tuberculosis.  Second,  open- 
air  instruction  in  ordinary  schools  as  an  integral  part  of  the  regular  curricu- 
lum, considered  as  an  essential  element  in  that  upbuilding  of  the  general 
health  that  constitutes  the  essential  preventive  of  all  diseases,  including 
specifically  all  forms  of  tuberculosis  and  serious  nervous  disorders.  Third, 
the  use  of  vacation  and  holiday  opportunities  for  life  in  the  open,  considered 
in  relation  to  family  conditions,  and  in  the  interest  of  general  health,  and 
the  intelligent  use  of  preventive  and  curative  methods.  (1)  The  first 
"fresh-air  school,"  so  called,  in  this  country  was  established  in  Providence, 
R.  I.,  in  1907-08.  The  origin  of  the  experiment  was  as  follows:  At  the  Anti- 
tuberculosis Congress  in  Washington,  D.  C,  the  preceding  winter,  a  physi- 
cian suggested  the  idea  of  an  open-air  school  for  children  from  tuberculous 
families.  Two  delegates  to  that  congress  from  Providence,  R.  I.,  carried 
the  ideal  suggestion  home  with  them,  and  brought  it  before  the  Local  League 
for  the  Suppression  of  Tuberculosis  as  a  practical  possibility.  The  way  had 
been  prepared  for  such  an  experiment  in  Providence  by  a  "day  camp"  for 
children  suffering  from  "glandular,  joint,  and  incipient  pulmonary  tubercu- 
losis," managed  by  two  women  physicians,  one  of  them  a  medical  inspector 
of  the  city  schools,  who  provided  the  grounds  of  her  own  residence  for  the 
camp.  The  advantages  of  this  day  camp  had  been  so  obvious  that  when 
the  league  indorsed  the  suggestion  of  a  regular  day  school  for  tuberculous 
children,  the  school  board  of  the  city  appointed  a  committee  of  five  members 
to  consider  the  scheme.  On  the  favorable  report  and  recommendation  of 
this  committee  the  school  board  started  and  carried  on  the  work  at  public 
expense.     The  official  account  says: 

"  An  unused  public  building,  formerly  a  cooking-school,  was  made  avail- 
able by  cutting  out  nearly  the  whole  southern  brick  wall,  and  replacing  it 
by  long  windows,  which  were  hung  from  the  top  and  opened  inward.  Chil- 
dren with  hip-joint  disease  or  enlarged  glands,  or  those  at  the  time,  or  who 
had  been  in  the  near  past,  closely  associated  with  open  cases  of  tuberculosis, 
were  selected  for  the  school  by  district  nurses  and  the  medical  inspectors. 

612 


THE   OPEN-AIR   SCHOOL. — SPENCER.  613 

Warm  sitting-out  bags  were  made,  and  provided  by  a  sewing  society  of  one 
of  the  churches,  and  all  else  was  supplied  by  the  city.  Some  very  severe 
cold  weather  was  experienced,  but  the  windows  always  remained  open;  and 
by  hot  soapstones  in  the  sitting-out  bags,  a  hot  drink  at  recess,  and  frequent 
trips  to  the  stove,  neither  teacher  nor  pupils  were  uncomfortable."  "The 
ages  of  the  children  ranged  from  seven  to  thirteen  years,  and  the  grades 
represented  from  one  to  eight."  "Two  sessions  were  held,  the  first  from 
9  A.M.  to  11.45  A.M.,  and  the  second  from  1.45  to  3.30  p.m.  During  the 
morning  session  a  half-hour  recess  was  given,  in  which  the  children  played 
out  of  doors  in  fair  weather  for  twenty  minutes,  and  for  the  last  ten  minutes 
sat  quietly  in  one  corner  of  the  room  and  drank  a  cup  of  hot  soup."  The 
windows  were  closed  at  the  noon  hour,  and  many  children  brought  their 
lunch  and  ate  it  at  the  school.  This  they  were  encouraged  to  do  when  Uving 
at  a  distance.  The  largest  number  registered  was  twenty-five;  the  average 
attendance  was  not  above  twenty.  The  name  of  the  school  was  carefully 
chosen,  so  as  not  to  prejudice  any  of  the  parents  against  it.  All  special 
instruction  in  regard  to  tuberculosis  was  avoided,  so  as  not  to  emphasize 
disease  in  the  school,  the  instruction  in  hygiene  following  the  regular  school 
course.  The  children,  however,  were  especially  under  the  care  of  the  medical 
inspectors  of  the  city  schools,  and  then-  condition  was  carefully  watched, 
and  connection  was  made  with  nurses  and  doctors  in  charge  of  cases  of 
diseases  at  their  homes. 

"The  eye  test  for  tuberculosis  was  tried  on  all  the  children,  and  practi- 
cally all  responded."  The  children's  weight  was  taken  regularly  as  often  as 
once  in  two  weeks.  "There  was  no  head  colds  or  other  troubles  of  similar 
nature  with  which  these  children  are  ordinarily  afflicted." 

Although  the  short  time  in  which  this  school  has  been  in  operation  makes 
it  still  exi3erimental,  and  although  the  fact  that  some  of  the  children  attend- 
ing it  come  from  homes  in  which  poverty  prevents  the  proper  supi^lement 
to  the  school  effort,  enough  seems  to  have  been  accomphshed  to  justify  high 
hopes  for  this  method  of  dealing  with  children  of  the  classes  described.  It 
gives  them,  for  a  large  portion  of  their  waking  time,  the  right  environment 
for  their  physical  condition,  and  at  the  same  time  keeps  them  in  line  with 
ordinary  children  in  their  school  work,  thus  preventing  depression  from 
either  idleness  or  fear  of  "getting  behind,"  and  helping  them  toward  a  self- 
supporting  life. 

The  methods  of  this  "fresh-air  school"  seem  not  unlike  those  of  the 
Waldschule  of  Germany,  and  is  only  modified  by  local  conditions  and  the 
requirements  of  school  from  the  general  scheme  of  open-air  treatment  for 
incipient  treatment  of  tuberculous  troubles.* 

*  An  account  of  this  fresh-air  school  is  given  in  the  May  number  of  the  "Journal 
of  the  Outdoor  Life." 


614  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

A  day  camp  school  of  out-of-door  life  has  been  opened  recently  by  the 
Boston  Association  for  the  Rehef  and  Control  of  Tuberculosis,  on  hospital 
grounds  in  that  city.  A  temporary  building  has  been  erected  for  Idtchen, 
storeroom,  and  lavatory  uses.  A  distinctive  feature  of  tliis  experiment  is 
the  laying  out  of  vegetable  and  flower  gardens,  in  which  the  children  of  the 
day  camp  work,  and  the  products  of  which  they  receive.  A  nurse  visits  the 
homes  of  all  in  the  camp;  each  child  receives  careful  physical  examination, 
and  special  physical  culture  based  upon  it  for  the  correction  and  develop- 
ment of  the  physique.  Such  a  day  camp  has  also  been  a  feature  of  the  anti- 
tuberculosis work  in  Providence,  R.  I.,  in  connection  with  a  large  hospital, 
with  grounds  airy  and  spacious,  w^iich  the  children  of  the  fresh-air  school 
have  attended  during  the  summer  vacation.  Several  similar  camps  are 
maintained  in  different  parts  of  the  country,  including  the  special  and  ex- 
tensive work  in  connection  with  the  "Island  Hospitals"  of  New  York 
city. 

There  is  no  doubt  that  the  day  camp  for  tuberculous  patients,  adult  and 
children,  has  come  to  stay;  and  the  inevitable  accompaniment  of  all  curative 
agencies  for  children  afflicted  with  any  disease  involving  prolonged  treat- 
ment is  a  school  in  which  conditions  can  be  adjusted  to  their  peculiar  needs, 
and  in  which  all  able  to  stand  any  strain  of  study  may  acquire  an  education 
while  they  are  gaining  health.  Thus  the  fresh-air  school  of  Providence, 
R.  I.,  although  a  small  experiment,  and  not  under  altogether  ideal  condi- 
tions, is  a  pioneer  indication  of  what  will  be  a  growing  contribution  to  the 
campaign  against  the  white  plague. 

2.  Experiment  in  the  direction  of  sjiecific  open-air  schools  for  those 
actually  in  need  of  curative  measures  has  led  directly  to  a  more  radical  in- 
quiry as  to  the  possibility  of  increasing  opportunities  for  exercise  and  study 
in  the  open  air  for  all  children,  and  in  connection  with  the  regular  instruction 
of  all  schools.  The  example  of  the  Providence  School  Board  in  ''cutting  out 
southern  brick  walls  and  inserting  in  their  stead  long  windows  hung  from  the 
tops  and  opening  inward,"  and  thus  capable  of  immediately  furnishing  an 
open-air  room,  might  well  be  followed  by  the  school  boards  of  all  cities, 
and  all  country  towns  as  well.  The  atrocious  "heating  systems,"  that  for- 
bid any  opening  of  windows  on  pain  of  disturbing  their  mechanism,  might 
thus  get  their  c^uietus. 

Some  points  connected  with  the  subject  of  out-of-door  air  in  school-rooms 
should  be  emphasized  strongly.  Among  these  is  the  fact  that  the  supremely 
essential  element  in  preventive  work  against  any  disease  is  the  elevation  of 
the  standard  of  general  health  in  the  community.  The  weak  person,  the 
ill-fed  person,  the  overtired  person,  succumbs  most  easily  to  the  effects  of 
improper  physical  surroundings,  and  has  no  power  to  resist  the  attacks  of 
disease.     The  strong,  well-nourished,  well-developed  person  can  withstand 


THE   OPEN-AIR    SCHOOL. — SPENCER.  615 

infection,  escape  sickness,  and  overcome  incipient  disorders  to  a  marked 
degree. 

Mothers  often  say  that  it  gives  them  a  headache  to  visit  school  all  the 
morning.  Yet  their  children  remain  in  the  stale  or  even  foul  air  that  is 
generally  responsible  for  the  mother's  headache,  and  the  adult  members  of 
the  family  wonder  why  they  are  not  robust.  No  one  seems  as  yet  to  have 
invented  a  plan  for  freshening  the  air  in  wliich  a  large  number  of  people  live 
and  work,  equal  in  good  effect  to  opening  a  wide  windov/  space  and  letting  a 
rush  of  pure,  unused  air  into  the  room  so  occupied.  Many  are  coming  to 
see  that  the  school-rooms  must  be  made  more  healthful  in  this  respect  for 
children,  or  the  appetite  will  suffer,  the  power  of  properly  absorbing  nourish- 
ment fail,  the  strength  to  resist  disease  germs  be  lacking,  and  the  bone- 
making  and  the  muscle-making  power  of  the  organism  decrease,  and  con- 
sequent nervous  dirorders  ensue.  Therefore  that  essential  preventive  of  all 
disease  we  call  "general  health"  demands  more  fresh  air  in  the  regular  schools. 

There  should  be  at  least  one  side  wall  in  each  school-room  made  up 
chiefly  of  glass  doors.  These  should  be  opened  wide  as  often  as  once  every 
hour,  during  a  ten-minute  singing,  marching,  and  light  gymnastic  exercise, 
in  which  rapid  movement,  in  really  fresh  air,  can  give  life  and  animation. 
After  such  an  "air-bath,"  teacher  and  pupil  could  settle  to  another  hour  of 
work  with  less  resulting  headache  than  is  now  the  rule  in  school  activity. 

Next,  a  general  education  of  the  parents  and  teachers  should  be  begun, 
leading  toward  the  opening  of  the  side  walls  of  such  school-rooms  for  all 
school  work  which  may  be  safely  and  effectively  done  in  the  open.  For  in- 
stance, manual  training,  with  its  activities,  including  the  use  of  the  stove 
in  domestic  science  work,  all  singing  practice  that  allows  of  body  motion, 
and  many  elements  of  physical  science,  might  well  be  pursued  in  a  room 
open,  at  least  on  one  side,  to. the  out-of-doors.  If  extra  wraps  are  needed, 
they  should  be  used.  Moreover,  all  physical  training  with  apparatus  should 
be  given  in  the  open  air,  or  as  near  it  as  can  be  managed.  It  is  not  merely 
a  "  cool  room  for  exercise"  that  is  needed,  but  a  place  in  which,  at  every 
inhalation,  made  deep  and  strong  by  the  exercise,  there  may  be  absorbed 
really  fresh  air.  Where  there  is  sufficient  land,  a  gymnasium  with  at  least 
two  walls  that  can  be  annihilated  by  opening  windows,  should  be  the  rule. 
In  the  crowded  cities.  Dr.  Gulick's  suggestion  of  many  tiers  of  roofs  for  play- 
ground and  physical  culture  use,  rising  above  the  school-rooms,  should  be 
adopted. 

Again,  enlightened  pedagogy  and  the  upbuilding  of  the  general  health 
of  school-children  alike  demand  the  "school  excursion"  and  the  "outdoor 
nature  study."  The  school  excursion,  as  developed  in  Germany,  would 
apparently  need  serious  modification  before  it  could  become  an  adjunct  to 
our  American  public  schools.    The  best  schools,  private  and  public,  how- 


616  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

ever,  in  the  United  States  now  use  the  school  excursion  freely  for  teaching 
geography,  history,  physical  science,  and  the  habits,  activities,  and  conditions 
of  contemporaneous  human  life.  The  extension  of  this  form  of  instruction 
may  lead  to  longer  school  days,  each  of  which  will  contain,  when  the  weather 
permits,  an  hour  or  more  of  "walking  lessons,"  in  which  children  and  teacher 
shall  be  called  outward  in  thought  and  activity  and  learn,  as  the  traveler 
learns,  by  observation  and  interchange  of  thought,  as  they  walk  and  talk 
together. 

Another  aid  to  the  importation  of  fresh  air  into  education  is  the  move- 
ment toward  "school  gardens,"  and  the  introduction  of  agriculture  and 
horticulture  into  the  school  curriculum.  Oklahoma  requires  such  instruc- 
tion in  its  public  school  system,  doubtless  with  a  view  to  vocational  use  of 
the  training  thus  received.  Anything,  however,  that  emphasizes  the  out-of- 
door  employments  and  introduces  the  child  to  the  delightful  companionship 
of  "green  things  growing"  leads  inevitably  to  more  healthful  life.  The  use 
of  vacant  lots  for  such  gardens,  the  effort  to  secure  small  parks  around  every 
school-house,  the  extension  of  the  kindergarten  flower-beds  up  tlirough  the 
grades,  even  where  they  must  be  window-boxes  for  want  of  outdoor  space — 
all  these  things  tend  mightily  toward  enlarging  the  educational  field  on  the 
side  of  health. 

3.  The  third  and  last  division  of  the  subject  embraces  the  use  of  vacation 
and  holiday  opportunities  for  life  in  the  open  air,  considered  in  relation  to 
hygienic  methods  of  family  living,  and  in  the  interest  of  general  health  and 
of  intelligent  use  of  preventive  and  curative  measures. 

Summer  vacation  camps  for  boys  and  for  girls  are  now  fashionable,  but, 
as  has  been  said,  "only  the  very  rich  or  the  very  ]30or  can  afford  them." 
For  the  poor,  who  accept  the  fresh-air  charities,  we  can  only  urge  that  more 
attention  than  is  common  be  paid  to  the  physical  condition  of  each  cliild, 
and  that  the  country  week  or  fortnight  allotted  them  be  used  more  often 
than  is  now  clone  as  a  means  of  inculcating  health-giving  habits.  In  the 
larger  portion  of  the  United  States  a  pressing  need  that  is  beginning  to 
be  met,  but  in  a  wholly  inadequate  manner,  is  for  the  summer  camp  life  for 
the  whole  family.  It  should  be  provided  near  enough  to  the  work-places 
of  the  bread-winners  to  admit  of  travel  back  and  forth  each  day,  or  at 
least  once  a  week,  and  while  not  a  charity,  its  benefits  should  be  obtain- 
able at  terms  within  the  means  of  people  of  small  incomes.  The  great  middle 
class  of  the  United  States,  working  in  cities,  including  many  persons  in  the 
professional  ranks,  cannot  afford  two  homes;  cannot  accept  any  summer 
outing  for  their  children  in  which  they  do  not  share,  unless  they  can  choose 
their  children's  comrades;  must  themselves  have  refined  surroundings  in  the 
country  or  stay  at  home.  Such  people  often  suffer,  more  than  those  less 
fastidious  as  to  companionship,  in  the  cramped  quarters  of  city  homes,  in 


THE    OPEN-AIR    SCHOOL. — SPENCER.  617 

the  torrid  heat  of  our  summers,  and  their  children  keep  their  "better  man- 
ners and  morals"  at  the  expense  of  their  physical  health,  during  the  long 
vacation  when  the  children  of  the  tenements  "  live  on  the  streets." 

The  Chautauquas  of  the  country  have  led  in  the  development  of  out-of- 
door  life  for  families,  combined  with  refined  and  congenial  companionship, 
lessons  for  the  children  in  nature,  art,  science,  music,  dancing,  etc. — in  the 
combination  of  school  and  camp  on  a  basis  of  small  expense.  This  move- 
ment means  as  much  for  the  general  health  as  for  the  educational  and  higher 
social  life.  It  is,  however,  wholly  inadequate  to  the  need,  not  only  because 
too  limited  in  extent,  but  also  because  too  far  removed,  as  a  rule,  in  its  oper- 
ations from  the  great  cities,  for  the  majority  of  families  of  the  sort  described 
to  take  advantage  of  its  benefits. 

Two  instances  may  be  named  of  rather  haphazard  provisions  for  family 
camping  that  hint  at  what  might  be  done  along  this  line.  On  Pelham  Bay, 
in  a  city  park  of  New  York  city,  a  place  swept  by  salt  breezes,  hundreds  of 
tents  are  erected  and  occupied  everj^  summer.  The  lots,  25  by  100  feet, 
are  loaned  by  the  park  commissioner  free  to  suitable  persons.  On  these  the 
people  put  up  and  remove  their  own  tents.  The  city  water  is  conveniently 
at  hand,  supplied  from  hydrants  at  short  distances  from  one  another  on  the 
tent-village  street.  Sanitary  arrangements  are  intended  to  be  first  class, 
but  some  criticism  might  be  made  in  regard  to  toilet  accommodations. 
All  seems  to  be  neat  and  well  cared  for  in  the  camps,  and  a  good  class  of 
wage-earning  people  evidently  take  advantage  of  this  opportunity  for 
out-of-door  life,  with  bathing,  boating,  fishing,  and  walks  in  park  reserva- 
tions at  hand. 

The  city  of  Newark,  N.  J.,  owns  and  operates  a  farm  of  eleven  and  one- 
half  acres  near  Avon-by-the-sea,  for  the  benefit  of  children  primarily,  but 
also  including  many  mothers  and  a  few  fathers  in  its  out-of-door  opportun- 
ity. Two  kindergartners  and  a  physician  aid  gratuitously  in  caring  for  the 
children,  and  an  attendance  officer  from  the  Board  of  Education  is  detailed 
for  service  at  the  farm ;  a  trained  nurse  is  sent  for  the  season  from  the  Board 
of  Health,  and  a  volunteer  committee  do  the  large  amount  of  executive 
work  entailed. 

These  are  but  suggestive  hints  of  what  should  be  attempted  in  specific, 
well-directed  plans  for  easy  access  to  the  country  by  families  of  moderate 
means.  Something  more  refined  in  its  opportunity  and  giving  chance  for 
more  family  privacy  than  the  Pelham  Bay  Camp  affords  is  needed.  Some- 
thing more  extended  and  giving  better  opportunity  for  the  whole  family 
to  live  together  in  the  country  through  the  summer  than  the  New  Jersey 
Camp  offers  is  required.  Small,  simple,  inexpensive  wooden  cottages,  such 
as  those  so  common  at  shore  resorts,  like  Martha's  Vineyard,  Mass.,  erected 
by  the  municipality  on  its  own  land,  and  rented  at  a  merely  nominal  sum, 


618  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

covering  the  interest  on  cost  of  the  cottage,  but  not  of  the  land — these  might 
form  the  right  basis  for  the  ideal  family  camp  near  large  cities.  The  estab- 
lishment and  maintenance  of  a  first-class  vacation  school  and  recreation  center 
for  the  cliildren  of  these  families  at  public  expense;  the  detailing  of  trained 
nurses,  physicians,  and  all  proper  officers  of  boards  of  health  and  of  education 
to  make  and  keep  the  camp  a  model  in  regard  to  health,  order,  quiet,  pleasant 
associations,  and  proper  amusements;  the  prohibition  of  all  "concessions" 
for  amusements  of  the  commercial  sort,  and  for  all  stores  except  those 
needed  to  supply  the  table  and  the  ordinary  household  needs  of  the  family; 
the  encouragement  in  all  possible  ways,  possibly  by  a  volunteer  agency,  of 
festivals  and  musical  and  other  entertainments  of  a  high  character — all 
these  things  are  possible  and  should  be  immediately  attempted  as  soon  as 
family  camps  can  be  established. 

To  sum  up:  First,  open-air  schools  must  be  provided  in  abundance,  as 
accompaniments  of  all  curative  agencies  for  children  afflicted  with  any  form 
of  tuberculosis  or  similar  wasting  disease  necessitating  prolonged  treatment. 

Second,  since  improving  the  general  health  of  all  the  people  constitutes 
an  essential  of  permanent  control  or  prevention  of  all  diseases,  and  since 
some  measure  of  open-air  life  is  an  essential  element  of  such  bettering  of 
general  health,  the  education  of  all  children  should  be  connected  more  than 
it  is  at  present  with  out-of-door  activities  and  pleasures. 

Third,  since  the  health  of  fathers  and  mothers,  as  well  as  that  of  children, 
is  an  essential  part  of  preventive  work  against  disease,  and  since  family 
life  determines  largely  the  health  conditions  of  both  the  jDresent  and  the 
coming  generations,  one  great  social  need  is  for  more  and  easier  access  to 
country  life  for  families  of  restricted  means,  who  live  and  work  in  the  cities. 
Hence  ''family  camps,"  with  public  schools,  organized  and  supervised 
playgrounds,  health  and  police  municipal  inspection  and  control,  medical 
attendance,  and  the  offices  of  trained  nurses  should  be  established  each 
summer  by  municipalities  or  private  enterprise  on  such  terms  as  to  meet 
this  need.  The  outer  rim  of  the  park  systems  of  some  cities  might  so  be 
utilized,  vacant  lots  be  secured  for  this  purpose,  and  outlying  districts  of 
growing  cities  withheld  from  speculators'  monopoly  for  this  benefit  of  the 
people. 

Above  all,  since  the  most  effective  ameliorative  treatment  of  those  in- 
fected with  disease  is,  from  a  social  point  of  view,  but  "locking  the  stable 
door  after  the  horse  is  stolen,"  great  emphasis  in  the  white  plague  campaign 
should  be  placed  on  a  better  chance  for  healthful  family  living  for  the  multi- 
tude of  city  workers  of  limited  means. 


RELATION  OF  TUBERCULOSIS  TO  PARKS  AND 
PLAYGROUNDS. 

By  Howard  Bradstreet, 

Secretary,  Parka  and  Playgrounds  Association  of  New  York  City. 


The  movement  for  the  acquisition  and  development  of  parks  by  the  muni- 
cipaUty  has  had  its  rise  and  great  extension  almost  completely  since  1850. 
Parks  and  commons  existed,  indeed,  prior  to  that  date,  as  the  plans  of  many 
cities  testify.  But  the  administration  of  a  system  of  parks  as  a  large  and 
important  factor  in  the  city  government  is  a  recent  phase  of  municipal  ac- 
tivity. As  a  result  of  the  growing  appreciation  of  the  beauties  of  nature, 
of  the  desire  for  city  adornment,  and  of  friendly  civic  rivalry,  each  of  the 
154  American  cities  of  over  30,000  inhabitants  reports  in  1905  a  park  area 
ranging  from  a  single  acre  to  the  6979  acres  of  New  York  city. 

The  word  "park"  is  a  vague  term,  of  varying  significance,  blanketing 
with  equal  readiness  such  immense  tracts  as  Fairmount  Park,  the  modest- 
sized  ornamental  squares,  and  the  gores  and  triangles  remnant  from  the 
cutting  of  new  streets.  Of  whatever  size  or  function,  the  term  park  im- 
plies, by  tradition,  the  element  of  beauty  and  adornment  rather  than  that 
of  utility,  and  appeal  to  pride  in  the  city  beautiful  secures  the  funds  for  park 
extension. 

This  same  half-century  has  witnessed  the  creation  of  other  new  depart- 
ments of  municipal  activity  and  the  transformation  of  old  ones.  The 
establishment  of  the  germ  theory  of  disease  has  given  a  new  importance  to 
the  disposal  of  garbage  and  sewage,  to  the  necessity  for  pure  water  and 
milk,  for  the  need  of  flushed  streets,  and  even  the  extermination  of  the 
mosquito  has  assumed  an  entirely  new  aspect.  At  the  touch  of  medical 
science  subjects  hitherto  lowly  have  been  dignified  to  first  rank.  It  has  at 
once  made  possible  and  compelled  a  much  greater  activity  in  many  city 
departments. 

The  discoveries  relating  to  tuberculosis  are  of  value  to  the  advocates 
of  parks  and  to  the  park  department — 

1.  By  giving  a  new  basis  for  their  advocacy.  The  horror  of  a  large  city 
solidly  built  can  be  appreciated  only  by  those  who  are  compelled  to  pass  a 
summer  on  its  treeless  streets,  while  the  menace  to  health,  and  the  barren- 

619 


620  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

ness  of  actual  living  conditions,  can  be  known  only  to  those  whose  professions 
take  them  into  the  tenements,  or  who  treat  directly  with  the  tenement 
product.  But  the  appeal  for  parks  on  the  grounds  of  sentiment,  comfort, 
and  common  humanity  is  now  transformed  by  science  into  a  demand  that 
there  be  open  spaces  for  conserving  the  life  of  the  people. 

The  nature  of  tuberculosis  has  at  last  been  esta])lished,  and  the  condi- 
tions that  lead  to  its  development  and  to  its  extinction  are  now  understood. 
Sunshine  and  fresh  air  are  shown  to  be  as  essential  to  freedom  from  the 
disease  and  as  necessary  for  its  cure  as  pure  water  and  milk  are  essential  to 
freedom  from  typhoid.  There  were  many  advocates  of  a  pure  water-supply, 
of  cleanliness  in  street,  house,  and  person,  before  the  germ  theory  of  disease 
was  established.  But  it  was  not  until  the  scientists  had  learned,  and  the 
people  had  been  taught,  the  reasons  for  such  action  that  money  and  effort 
were  spent  without  stint  to  obtain  results  along  these  lines. 

For  the  prevention  of  typhoid,  ready  acquiescence  is  given  to  the  spend- 
ing of  limitless  sums.  When  once  the  lesson  of  the  educational  campaign 
regarding  tuberculosis  has  been  learned,  the  same  acquiescence  will  be  given 
to  expenditures  securing  adequate  light  and  pure  air.  Whether  established 
from  a  motive  of  civic  beauty,  of  civic  rivalry,  of  sentiment,  or  of  reason, 
parks  furnish  these  essentials,  and,  therefore,  the  foes  of  tuberculosis  look 
to  the  parks  for  supplies  of  war,  and  regard  them  as  an  active  ally  in  their 
campaign. 

Thus  medical  science  stimulates  and  dignifies  the  work  of  still  another 
city  department. 

2.  A  service  is  rendered  the  park  movement  by  laying  emphasis  upon  the 
need  for  numerous  small  neighborhood  parks,  rather  than  upon  the  large 
reservation  or  excursion  park. 

Tuberculosis  finds  its  readiest  triumphs  among  the  overworked  and 
underfed.  If  parks  and  playgrounds  are  to  help  turn  these  triumphs  of 
disease  into  defeats,  they  must  be  placed  strategically  in  largest  number, 
giving  freest  opportunity  for  use  among  that  class  of  citizens. 

A  large  reservation  that  is  little  used  by  the  people  may  exist  within  the 
limits  of  a  very  closely  built  city,  and  so  be  a  small  factor  in  the  life  of  the 
citizen.  The  test  of  the  value  of  the  park  is  in  the  number  of  its  daily  visi- 
tors, not  in  its  area. 

Many  students  of  the  city  life  from  time  to  time  have  advocated  the 
value  of  small  parks  and  urged  their  acquisition,  on  the  basis  of  health,  but 
there  has  not  yet  been  established,  among  people  or  authorities,  the  sense 
of  necessity  that  would  lead  to  effective  action. 

The  tuberculosis  campaign,  by  its  educational  work,  gives  promise  of 
such  results. 

3.  The  tuberculosis  campaign  gives  its  most  valuable  suggestion  to  the 


TUBERCULOSIS   AND    PARKS   AND    PLAYGROUNDS. — BRADSTREET.         621 

parks  in  urging  upon  them  a  larger  meaning  and  a  more  aggressive  policy  of 
administration. 

In  the  case  of  many  measures  taken  by  the  city  for  the  common  welfare 
the  benefits  are  bestowed  automatically.  It  is  quite  impossible  for  a  citizen 
not  to  profit  by  pure  water  provided,  or  to  benefit  from  the  sewer  system  or 
the  wholesome  effects  of  clean  streets,  but  such  is  not  the  case  with  the  fresh 
air  and  sunlight  furnished  by  parks. 

An  apartment  may  face  a  park  and  contain  dark  rooms,  or  the  occupants 
may  keep  the  windows  closed  and  leave  the  rooms  but  little,  and  thus  neglect 
the  opportunities  placed  at  their  doors.  It  does  not  necessarily  follow  that 
a  park,  any  more  than  a  library,  will  serve  the  welfare  of  those  most  needing 
its  services.  Indeed,  in  both  cases  the  first  patrons  will  be  those  who  have 
instincts  in  such  directions  to  gratify,  and  not  the  ones  in  whom  the  instinct 
is  yet  to  be  aroused.  This  fact  is  considered  in  the  conduct  of  libraries, 
where  it  is  found  as  necessary  to  stimulate  as  to  gratify  a  desire  for  read- 
ing. The  same  fact  is  also  noted  in  the  recent  growth  of  the  playground 
movement.  It  has  been  found  by  experience  that  it  is  not  enough  to  furnish 
apparatus,  but  there  must  also  be  a  personality  to  organize  and  stimulate 
the  children  in  order  to  bring  the  largest  returns  in  attendance  and  healthful 
activities.  Park  concerts  are  commonly  conducted  in  American  cities, 
and  serve  well  as  an  attraction  for  the  older  people,  and  act  as  an  induce- 
ment to  profit  by  the  fresh  air. 

A  park,  in  order  to  achieve  its  purpose  of  encouraging  life  out  of  doors, 
must  adapt  itself  to  its  neighborhood.  In  a  fine  residence  section,  where 
porches  or  ample  cool  rooms  exist,  the  function  of  a  small  park  is  not  the 
same  as  in  a  tenement  section.  While  beauty  is  always  desirable,  and  the 
fine  effect  of  a  green  sward  in  a  crowded  district,  is  uncUsputed,  nevertheless 
to  dedicate  one  or  two  acres  to  sanctified  grass,  while  the  people  must  sit  on 
the  sidewalk  beside  its  edge,  is  to  secure  but  a  small  return  of  usefulness  in 
proportion  to  the  possibilities  of  the  space.  In  many  sections,  during  the 
hot  weather,  eating  out  of  doors  in  the  neighborhood  park  could  be  encour- 
aged to  advantage,  disturbing  as  the  thought  might  be  to  a  conventional 
park  director. 

Still  another  use  of  park  property  suggested  by  the  tuberculosis  propa- 
ganda is  in  family  tent  life.  There  are  large  reservations  in  many  cities, 
usually  at  a  distance  and  on  some  waterway  or  height  of  peculiarly  healthy 
nature,  whose  use,  by  reason  of  distance,  is  confined  to  occasional  excursions. 
A  workman  threatened  with  tuberculosis  is  directed  to  live  out  of  doors, 
and  in  obeying  the  injunction  is  threatened  with  probable  loss  of  work. 
Were  it  possible  for  him  to  do  so  at  the  right  moment  for  sufficient  time,  the 
city  would  be  spared  the  loss  involved  in  his  breakdown  later.  The  reser- 
vation or  excursion  park  could  be  of  value  at  this  point  by  setting  aside 


622  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

certain  available  stretches  equipped  with  tents  for  family  life  under  most 
favorable  health  conditions. 

In  many  cities  the  Board  of  Health  already  provides  camps  for  the 
treatment  of  tuberculosis.  The  suggestion  that  the  jurisdiction  of  the  park 
board  might  be  extended  so  as  to  deal  with  an  allied  work,  illustrates  the 
inevitable  identity  of  interests  in  city  departments  when  dealing  with  the 
personal  welfare  of  the  citizen.  In  so  far  as  the  park  board  deals  with  trees 
and  soil,  the  school  board  with  books  and  laboratories,  the  health  board 
with  diseases  and  their  prevention,  each  has  a  distinct  field  for  expert  action 
of  widely  differing  natures.  But  in  all  there  is  a  border  territory  that 
compels  the  interest  of  the  health  authorities  in  school  and  park  affairs,  and 
that  makes  the  parks  interested  in  schools  and  health,  and  in  this  domain 
medical  science  is  leader  and  director. 

Finally,  the  park  problem  as  related  to  tuberculosis  becomes  allied  with 
the  housing  problem  and  town  planning.  Just  as  neighborhood  parks  have 
a  larger  significance,  when  properly  used,  than  large  and  ornamental  reser- 
vations, so  does  a  city  block  in  which  the  park  element  is  furnished  in  itself 
possess  a  greater  value  than  the  small  park.  Under  the  conditions  prevail- 
ing in  the  large  cities  at  present  it  is  not  only  possible,  but  it  is  the  custom,  to 
build  solidly  a  succession  of  blocks  with  no  provision  for  the  intimate  park 
element.  When  its  need  becomes  imperative,  financial  limitations  in  the 
value  of  the  property  to  be  acquired  make  only  a  minimum  number  of  open 
spaces  possible.  Such  a  plan  not  only  is  baneful  in  itself,  but  tends  to 
destroy  the  instinct  for  out-of-door  life  and  the  desire  for  exercise,  a  loss 
that  has  far-reaching  and  incalculable  results.  Already  the  substitution  of 
excitement  for  recreation  is  found,  and  the  parks  are  placed  in  unequal 
competition  with  amusement  resorts,  either  outdoors  or  indoors,  furnishing 
nerve  stimulation  rather  than  restful  enjoyment.  This  perversion  is  part 
of  the  human  adaptation  to  urban  conditions — an  adaptation  that,  in  the 
end,  will  be  far  more  expensive  to  society  than  the  providing  of  the  means 
for  enjoyment  of  nature,  expensive  as  that  process  may  be. 

In  so  far  as  the  movement  against  tuberculosis  urges  outdoor  life,  sun, 
and  pure  air,  in  so  far  does  it  stand  for  parks  and  playgrounds  for  young 
and  old,  so  placed  as  to  give  greatest  resources  to  the  greatest  number,  and 
secured  not  from  motives  of  sentiment,  but  from  the  most  fundamental  and 
compelling  that  can  advocate  any  cause — the  preservation  of  the  health  of 
the  present  and  of  future  generations. 


THE  HYGIENIC  AND  CLIMATIC  PROPHYLAXIS  OF 
TUBERCULOSIS  IN  CHILDHOOD. 

By  Frederick  L.  Wachenheim,  A.B.,  M.D., 

New  York. 


The  higher  aims  of  medical  science  seek  prevention  rather  than  cure. 
In  combating  tuberculosis,  which  so  often  begins  in  infancy,  blights  the  fair 
promise  of  childhood  and  adolescence,  usually  terminates  in  premature 
death,  and  imposes  a  tremendous  economic  burden  upon  the  community, 
our  energies  must  needs  turn  to  an  efficient  prophylaxis.  As  our  knowledge 
of  the  etiology  and  pathology  of  tuberculosis  has  increased,  it  has  become 
more  and  more  evident  that  this  prophylaxis  must  be  begun  early — in  infancy 
and  childhood.  The  subject  of  the  prevention  of  tuberculosis,  in  its  entirety, 
is  far  too  vast  for  discussion  here;  for  this  reason,  only  such  matters  as 
relate  to  personal  hygiene,  including  the  general  regimen  of  Ufe  and  the 
choice  of  residence,  the  last  considered  essentially  as  regards  the  elements 
of  cUmate,  will  be  dealt  with  in  tliis  article. 

Good  general  nutrition  has  always  been  considered  as  one  of  the  best 
preventives  against  tuberculosis.  This  is  so  far  true  that  a  loss  of  weight 
invariably  accompanies  a  progressive  state  of  this  disease,  but  is  not,  of 
course,  true  of  the  converse.  It  is  also  a  common  fallacy,  especially  in  our 
sanatoriums,  to  consider  an  increase  in  weight  a  sign  of  improvement, 
whereas  it  is  no  difficult  matter  to  fatten  any  patient  who  is  not  rapidly  or 
at  least  progressively  going  down  hill,  by  enforcing  a  quiet  life  and  supplying 
an  ample  dietary.  Nevertheless,  we  may  regard  a  reasonable  amount  of 
adipose  tissue  as  an  indication  of  some  individual  resistance  to  the  tubercle 
bacillus.  Children,  especially,  who  suffer  from  what  we  term  scrofulosis, 
thereby  showing  either  susceptibility  to  tuberculosis  or  the  presence  of  one 
of  its  chronic  forms,  regularly  improve  if  a  gain  in  weight  can  be  effected. 

Our  greatest  difficulty  is  with  children  who  suffer  from  anorexia,  which 
may  be  a  sign  that  tuberculosis  is  already  estabhshed,  for,  on  the  other  hand, 
may  be  merely  the  manifestation  of  a  neurosis  or  a  perverted  metabolism, 
or  be  due  to  vicious  habits  of  eating  or  to  dental  caries.  In  these  cases  we 
must  begin  by  correcting  any  causative  factors  that  may  be  present,  paying 
particular  attention  to  the  candy  and  caffein  habits  and  to  painful  teeth. 

623 


624  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

Neurotic  cliildren  must  not  be  permitted  to  associate  with  older  or 
overstrenuous  companions,  and  should  be  guarded  against  nervous  excite- 
ment. A  sufficient  amount  of  restful  sleep  should  also  be  procured.  Over- 
work at  school  is  uncommon  nowadays,  but  too  many  children  remain  at 
home  reading  when  they  should  be  out  of  doors.  An  outdoor  life  may 
sometimes  be  secured  most  readily  by  moving  from  the  city  to  the  suburbs, 
to  a  milder  and  sunnier  climate,  or  to  the  more  bracing  concUtions  at  the 
seaside  or  in  the  mountains;  this  will  be  discussed  more  fully  further  on. 
The  chronic  constipation  that  regularly  accompanies  the  anorexia  of  children 
is  usually  only  concomitant,  but  may  sometimes  call  for  special  treatment. 

The  diet  of  cliildren  should  be  as  varied  as  possible,  excluding  highly 
seasoned  foods  and  stimulants  of  all  kinds,  including  tea  and  coffee.  Eggs 
and  cereals,  bread,  and  plenty  of  good  butter  and  milk  should  form  the  basis 
of  the  three  or  four  daily  meals;  meat  should  be  given  only  once  a  day  to 
young  children,  and  not  more  than  twice,  even  at  puberty.  Treatment  with 
fats,  especially  the  distasteful  cod-liver  oil,  is  not  regarded  so  highly  as  it 
formerly  was.  I  have  already  explained  that  mere  fatness  is  not  necessarily 
a  sign  of  robustness.  Nevertheless,  cream  and  butter,  in  moderate  quantity, 
are  usually  relished  by  children,  and  a  few  learn  to  enjoy  a  reasonable  amount 
of  pure  olive  oil;  these  fats  are  all  relatively  digestible  and  free  from  the  dis- 
gusting odor  and  taste  of  cod-liver  oil.  The  latter  is  said  to  be  becoming 
scarce,  and  other  and  still  more  unpleasant  fish  oils  are  not  infrequently 
substituted  for  it.  In  any  case  we  must  remember  that  fats  are  useful, 
especially  during  the  colder  months,  since  they  possess  calorie  value  in  its 
most  concentrated  form. 

The  carbohydrates  may  be  given  freely,  and  I  do  not  share  the  common 
prejudice  against  sugar,  which  is,  after  all,  but  the  equivalent  of  an  equal 
weight  of  starch.  The  only  objection  to  large  amounts  of  cane-sugar  is  that 
they  develop  the  candy  habit,  which  is  pernicious  because  of  the  inferior 
quality  of  sweets  usually  purchased,  and  because  of  the  secondary  develop- 
ment of  the  chocolate  habit,  which  is  merely  a  variation  of  the  reliance  on 
coffee  or  tea  as  a  stimulant.  Excessive  fondness  for  sugar  must  be  combated 
by  withholding  that  article  of  food  until  the  child  learns  to  do  without  it, 
or  by  narrowly  restricting  its  quantity.  The  oxybutyric  acidosis,  so  often 
observed  in  children,  is  probably  not  caused  by  the  excessive  ingestion  of 
carbohydrates.  Since  we  know  that  this  intoxication,  in  diabetics,  is  due 
to  a  too  strict  withdrawal  of  carbohydrates  and  an  excess  of  fat  and  albumin 
in  the  diet,  we  may  safely  conclude  that  in  children,  also,  this  affection  is  the 
result  of  an  excess  of  fatty  or  proteid,  and  not  of  carbohydrate,  food. 

Nothing  is  so  useful  to  stimulate  the  appetite  of  children  as  exercise,  if 
care  be  taken  not  to  push  it  to  the  point  of  exhaustion,  for  when  this  is  done 
the  digestive  apparatus  will  inevitably  suffer.    Exercise,  including  system- 


HYGIENIC   AND    CLIALA.TIC   PROPHYLAXIS. — WACHENHEIM,  625 

atic  gymnastics,  is  also  in  high  repute  as  a  prophylactic  measure  against  the 
development  of  tuberculosis,  but  it  is  as  well  to  subject  this  purely  empirical 
view  to  scientific  revision.  A  good  muscular  development  is,  without  doubt, 
a  useful  personal  asset  to  one  whose  vocation  in  later  life  calls  for  great  phy- 
sical strength.  Otherwise,  the  assiduous  cultivation  of  gigantic  muscles, 
which  is  quite  possible  to  any  one  under  scientific  management,  has  little 
permanent  value,  for  when  heavy  work  is  discontinued,  the  painfully  ac- 
quired hjqoertrophy  disappears  rapidly.  It  is  not  too  much  to  say  that  this 
sort  of  gymnastics  is  a  sheer  waste  of  time,  and  I  may  go  even  further,  and 
pointing  out  that  physical  overexertion,  especially  if  long  continued,  is  one 
of  the  immediate  causes  of  premature  arteriosclerosis,  and  is  likely  to  be 
associated  with,  at  least,  periodic  albuminuria.  It  may  be  argued  that  this 
phase  of  the  subject  hardly  concerns  us  here.  What  is  more  to  the  point 
is  that  careful  obsei'vation  seems  to  show  an  increased  susceptibility  to 
tuberculosis  among  record-holding  school  and  college  athletes*;  it  is  evident 
that  the  exhaustion  following  their  strenuous  competitions  favors  the  in- 
vasion of  disease;  and  athletics  of  this  type  should  absolutely  be  forbidden 
to  school-children.  It  is,  therefore,  to  be  regretted  that  efforts  are  now 
actively  under  way  to  foster  interscholastic  contests;  for  they  are  unques- 
tionably harmful  physically,  and  seem  to  be  even  more  pernicious  morally 
if  we  may  judge  from  recent  developments  in  so-called  amateur  sporting 
circles.  It  seems  to  me  that  our  liigher  institutions  are  acting  wisely  in 
trying  to  limit  the  field  of  competitive  athletics;  and  it  is  to  be  regretted  that 
the  secondary  schools  are  endeavoring  to  extend  it. 

Personally,  I  have  no  hesitation  in  declaring  that  I  see  no  value  in  ath- 
letics save  for  the  outdoor  life  they  involve;  from  this  point  of  view  the  less 
strenuous  games,  especially  those  in  which  the  vain  desire  to  break  records 
plays  no  part,  are  to  be  preferred  to  mere  feats  of  strength,  speed,  and  endur- 
ance. We  can  safely  favor  such  sports  as  tennis  and  baseball,  which  train 
the  eye  and  brain  as  well  as  the  muscles,  which  may  be  discontinued  when 
the  child  becomes  tired,  and  whose  rules  set  a  time  limit  of  a  few  hours. 
Indoor  games  and  gymnastics  are  far  inferior,  and  are  to  be  resorted  to  only 
for  special  purposes,  as  when  stormy  weather  interferes  with  life  out  of  doors. 
In  winter,  snow  and  ice  afford  opportunities  for  wholesome  sport  that 
cannot  be  replaced  by  the  best  gymnastic  apparatus.  In  orthopedic  prac- 
tice it  is  regularly  found  that  gymnastic  exercises  are  most  needed  by  chil- 
dren who  have  lived  indoors  too  much;  those  who  have  led  an  active  outdoor 
life  have  no  occasion  to  resort  to  dumb-bells  or  Indian  clubs.  I  may  be 
criticized  for  having  treated  exercise  merely  as  a  means  of  hardening,  and 
I  accept  the  criticism  cheerfully.  If  we  fortify  the  physique  against  that  arch- 
enemy of  early  life,  tuberculosis,  we  give  the  brain  a  chance  to  win  for  its 
*  I.  Coughlin:  Med.  Record,  June  2,  1906. 


626  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

owner  a  position  in  the  world  to  which  mere  muscle  will  hardly  serve  to 
raise  him. 

The  process  of  "hardening,"  has  long  been,  and  still  is,  regarded  as  our 
mainstay  in  coml^ating  a  tendency  to  tuljerculous  infection,  or  as  an  aid  in 
resisting  the  further  inroads  of  an  infection  already  acquired,  but  for  the 
time  being  latent  or  quiescent.  It  is  much  to  be  regretted  that  the  recent 
brilliant  investigations  bearing  on  the  doctrine  of  immunity,  with  all  their 
absorbing  interest  and  eventual  possibilities,  as  yet  throw  no  light  on  the 
merits  of  hardening  as  a  therapeutic  method.  Nevertheless,  its  value  in 
the  treatment  of  established  and  evident  tuberculosis  has  been  placed 
beyond  question,  and,  despite  its  empirical  status,  it  will  remain  for  the 
present  our  most  valuable  prophylactic  agent.  To  attempt  an  exact  defini- 
tion of  the  term  hardening  merely  begs  the  question.  The  degree  of  harden- 
ing sought  has  hitherto  varied  according  to  the  mental  attitude  of  the 
individual  clinician,  for  the  physiological  data,  that  should  aid  us  in  reducing 
tliis  procedure  to  some  sort  of  system  are  lamentably  incomplete. 

The  theory  of  catching  cold  is  one  of  the  most  actively  mooted  points  of 
pathology,  even  if  we  define  a  cold  as  an  acute  infection  of  the  respiratory 
tract.  Many  utterly  deny  that  a  sudden  chilling  of  the  body  can  cause  a 
cold,  only  a  few  accept  the  exposure  etiology  in  toto,  and  most  of  us  handle 
it  with  reservation  as  not  proved.  Although  an  advocate  of  this  view,  I 
admit  that  the  evidence  in  its  favor  is  very  inconclusive.  Furthermore,  the 
question  as  to  whether  a  cold  predisposes  to  tuberculous  infection  is  quite  un- 
settled, but  I  believe  that  the  invasion  of  the  tubercle  bacillus  is  undoubtedly 
favored  by  a  previous  infection  of  the  respiratory  tract,  as  happens,  for 
example,  after  an  attack  of  measles.  Moreover,  the  amount  of  protection 
that  hardening  affords  against  acute  respiratory  disease  is  still  in  dispute, 
and  the  same  may  be  said  concerning  the  degree  of  hardening  that  should 
yield  the  best  results.  Hecker  *  has  indeed  proved  that  excessive  hardening 
predisposes  to  colds,  but  no  one  has  furnished  really  satisfactory  evidence 
that  moderate  hardening  assists  the  organism  in  acquiring  even  relative 
immunity.  As  to  this  last  point,  we  are  still  on  an  entirely  empirical  basis; 
all  that  we  know  is  that  experience  shows  moderate  hardening  to  be  a  means 
of  defense  against  tuberculosis,  and  excessive  hardening,  so  called,  to  be  no 
hardening  at  all,  but  a  most  effective  method  of  lowering  the  general  resis- 
tance to  infection  of  the  respiratory  tract  with  the  organisms  that  cause 
acute  inflammation,  and  probably  tuberculosis  as  well. 

It  is  evident  that  we  cannot  draw  the  line  between  reasonable  and  ex- 
cessive measures  of  hardening  arbitrarily,  nor  can  any  sweeping  rule  be  laid 
down  to  guide  us,  unless  we  depart  from  our  standpoint  of  conservatism. 
Our  object  should  be  to  start  with  a  minimum,  and  to  work  up  to  a  higher 
*  Miinch.  med.  Woch.,  1902,  No.  45. 


HYGIENIC   AND    CLIMATIC    PROPHYLAXIS. — WACHENHEIM.  627 

degree  gradually,  taking  care  to  keep  witliin  the  range  of  tolerance  of  the 
particular  individual  before  us.  We  may,  however,  regard  two  points  as 
settled :  first,  that  the  patient  most  urgently  requiring  hardening  should  be 
handled  with  especial  gentleness  at  the  outset;  secondly,  that  hardening 
should  be  less  and  less  strenuous  as  approach  or  recede  from  the  age  of 
thirty  or  forty  years,  so  that  infancy  and  old  age  should  be  subjected  to  the 
mildest  measures  only.  These  two  principles  depend  on  the  well-laiown 
physiological  fact  that  the  efficiency  of  the  thermoregulatory  apparatus  of 
the  body  varies  accorcUng  to  age  and  individual  robustness :  to  reduce  them 
to  a  practical  basis,  it  will  be  necessary  to  adopt  the  working  formula  which, 
on  a  previous  occasion,*  I  have  designated  the  theory  of  the  indifferent 
temperature. 

By  the  term  "indifferent  temperature"  we  may  designate  that  atmos- 
pheric warmth  at  wliich  the  thermoregulatory  apparatus  of  the  body  is 
at  rest,  the  animal  heat  being  maintained  by  the  minimum  normal  respira- 
tory activity  alone.  Both  heat  and  cold  act  as  stimulants,  though  in  differ- 
ent ways.  Heat  can  be  counteracted  only  by  the  vasodilator  apparatus; 
this,  naturally,  becomes  exhausted  in  the  course  of  time,  producing  the  con- 
dition called  enervation.  Cold  may  be  combated  either  through  the  vaso- 
constrictor mechanism  or  through  muscular  exertion,  of  which  the  latter  may 
be  controlled  voluntarily;  in  addition,  we  have  the  auxiliary  means  of  cloth- 
ing and  artificial  heat,  so  that  our  physiological  resources  need  not  be  over- 
taxed. To  demonstrate  that,  properly  regulated,  either  heat  or  cold  may 
be  employed  as  a  tonic,  I  need  only  refer  to  the  Japanese  custom  of  hot 
bathing;  it  seems,  indeed,  as  if  their  method  were  preferable  in  some  ways 
to  our  cold  baths,  for  it  involves  no  risk  of  chilling  the  overheated  body 
surface.  As  to  the  ultimate  hardening  result,  the  Japanese  laborer  certainly 
leaves  notliing  to  be  desired  in  that  respect. 

The  hot  bath  is,  however,  the  only  means  of  employing  heat  as  a  harden- 
ing method  that  can  be  regulated;  for  general  use  the  employment  of  cold 
is  far  more  available,  since  our  climate  supplies  sufficiently  cool  air  during 
the  greater  part  of  the  year,  so  that  mere  life  out  of  doors  may  be  effectively 
utilized.  Cold  water  is  quite  readily  obtainable  at  all  seasons.  It  is  for 
these  reasons,  perhaps,  that  European  and  American  methods  of  hardening 
resort  to  the  application  of  cold  exclusively. 

We  are  now,  fortunately,  I  think,  entering  on  a  period  of  reaction  from 
the  mania  for  violent  hardening  which  existed  a  few  years  ago,  when  the 
most  popular  measures  amounted  to  positive  cruelty.  I  need  only  recall 
that  young  children,  even  infants,  preferably  those  that  appeared  delicate, 
were  plunged  into  cold  water  two  or  three  times  a  day,  and  that  nudity,  to 
the  limit  of  the  law,  was  regarded  with  favor.  Going  about  barefoot  indoors 
*  "Climatic  Treatment  of  Children,"  p.  7. 


628  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

at  all  seasons,  with  as  little  clothing  on  the  extremities  as  possible  out  of 
doors  in  summer,  are  still  widely  advocated,  the  great  object  evidently  being 
to  keep  the  child  uncomfortably  cold  all  the  time.  In  spite  of  the  absurd 
extremes  mentioned,  however,  the  general  principles  of  hardening  still  hold 
good,  provided  the  measures  applied  are  kept  witliin  rational  bounds. 
I  may,  therefore,  at  this  point  give  a  brief  outUne  of  such  methods  as  seem 
to  me  reasonable  and  adequate,  neither  pampering  and  enervating  the 
cliildren,  nor,  on  the  other  hand,  exposing  them  to  unnecessary  discomfort 
and  risk. 

Children  should,  of  course,  be  out  of  doors  as  much  as  possible:  this 
sounds  axiomatic,  but  is  not  so  easy  to  carry  out  in  the  more  congested  city 
wards,  especially  among  the  poor,  where  the  mother's  manifold  household 
duties  keep  her  and  her  family  at  home  nearly  all  day.  Thus  I  see  many 
instances  where  promising  infants  gradually  fall  below  normal,  merely  be- 
cause they  are  taken  out  only  once  or  twice  a  week,  even  in  pleasant  weather. 
In  this  connection  we  may  note  with  interest  the  observations  of  Hanse- 
mann,*  which  I  have  been  abundantly  able  to  verify.  Without  ignoring 
the  harmful  effects  of  artificial  feeding,  he  attributes  rickets  chiefly  to  what 
he  aptly  calls  imperfect  domestication;  in  other  words,  he  considers  man 
still  imperfectly  adapted  to  an  indoor  life,  and  regards  that  form  of  mal- 
nutrition which  we  call  rachitis  as  due  to  insufficient  fresh  air  and  sunlight. 
I  might  add  that  many  obscure  forms  of  anemia  are  also  unquestionably 
caused  by  living  in  the  semidarkness  of  many  of  our  city  rooms.  Similar 
conditions  once  were  common  in  prisons,  and  may  still  be  observed  in  miners. 
It  seems  that  children,  as  well  as  plants  and  most  of  the  lower  animals, 
thrive  to  perfection  only  out  of  doors.  It  also  seems  that  these  rachitic 
and  anemic  children  are  more  susceptible  to  tuber-culosis  than  those  that 
are  more  robust;  it  is  certain  that  many  of  them  acquire  a  chronic  or  a  latent 
tuberculous  infection  in  very  early  life,  as  we  cannot  otherwise  account  for 
the  relative  frequency  of  glandular  enlargements  in  this  group. 

During  the  first  month  of  infancy  the  thermoregulatory  apparatus  of 
the  body  still  functionates  very  imperfectly,  so  that  exposure  to  cold  easily 
reduces  the  temperature  to  the  subnormal.  Tliis  condition  has  been  shown 
by  experience,  even  more  than  by  experiment,  to  favor  the  development  of 
acute  respiratory  or  gastro-intestinal  disease.  New-born  infants  must, 
therefore,  be  kept  indoors;  an  outing  may,  however,  be  permitted  in  the 
third  or  fourth  week  in  midsummer  weather.  After  the  first  month  of  life, 
the  baby's  first  outing  depends  on  the  season  of  the  year.  It  is  well  to  re- 
member that  the  first  airing  should  be  taken  when  the  temperature  is  at 
least  70°  F.  (21°  C.)  and  during  calm  and  sunny  weather.  Later  on,  of  course, 
a  lower  temperature  will  suffice,  but  it  is  evident  that  a  baby,  born  at  the 
*  Berlin,  klin.  Woch.,  February  26,  1906. 


HYGIENIC   AND    CLIMATIC    PROPHYLAXIS. — WACHENHEIM.  629 

beginning  of  the  winter,  may  have  to  be  kept  indoors  for  months  if  its  native 
cUmate  be  cold  or  damp. 

Toward  the  end  of  the  first  year  low  temperatures  may  be  largely  dis- 
regarded; our  very  cold  days— I  am  speaking  of  the  middle  Atlantic  coast — 
are  nearly  always  sunny,  though  sometimes  windy,  so  that  the  infant  may 
be  stationed  on  the  sunlit  eastern  or  southern  side  of  a  building  during  the 
forenoon,  thereby  being  sheltered  from  our  keen  northwest  winds.  Under 
these  conditions  a  temperature  well  below  the  freezing-point  is  easily  borne. 
I  have  seen  infants  in  their  second  half-year,  well  bundled  up,  basking  in  the 
sun  on  some  of  our  most  severe  days,  in  evident  comfort.  The  rule,  occa- 
sionally laid  down,  to  keep  infants  indoors  when  the  temperature  falls  below 
20°  F.  ( — 7°  C.)  need  not  be  so  strictly  adhered  to;  it  practically  involves 
imprisonment  far  northward,  but  exposure  to  relatively  severe  cold  in  the 
south.  We  must  not  forget  that  40°  F.  (4°  C.)  seems  as  cold  at  New  Or- 
leans as  zero  ( — 18°  C.)  at  Montreal,  because  the  normal  winter  temperatures 
are  respectively  15°  F.  (8°  C.)  higher.  Sensitiveness  to  cold  is  largely  a  rela- 
tive matter,  depencUng  on  what  we  have  become  habituated  to.  It  is  a 
case  where  sound  judgment  will  be  a  better  guide  than  any  formulated  rule. 

After  the  age  of  two  3'ears,  mere  cold  may  be  cUsregarded  altogether, 
whereas  dampness  and  high  winds  are  still  harmful.  As  the  school  age  is 
approached  children  should  be  kept  at  home  only  when  it  rains,  a  dry  and 
cold  snow-storm  being  relatively  unobjectionable. 

In  this  connection  I  must  animadvert  briefly  on  the  so-called  house- 
airing,  frequently  recommended  to  timid  parents  as  a  substitute  for  outdoor 
Hfe;  as  a  matter  of  fact,  it  is  not  even  a  poor  imitation  thereof,  but,  on  the 
contrary,  a  measure  replete  with  danger.  I  need  only  recall  that  the  cliild 
is  exposed  to  a  cold  draft  at  every  inadvertent  opening  of  the  door,  con- 
cUtions  that  do  not  obtain  on  a  veranda  or  in  an  open  tent,  where  there  are 
no  considerable  contrasts  of  temperature  and  the  air-currents  are  diffused. 
I  must  also  add  a  few  words  of  condemnation  of  the  solarium,  referring  only 
to  its  close  resemblance  to  the  gardener's  hot-house;  hardening  may  often 
become  irrationally  excessive,  but  hot-house  treatment  is  absolutely  inde- 
fensiljle  in  dealing  with  healthy  cliildren. 

When  the  child's  native  climate,  in  combination  with  individual  lack  of 
robustness,  prevents  the  enjoyment  of  any  great  measure  of  outdoor  life,  a 
change  of  air  is  indicated.  As  we  rarely  need  to  resort  to  climatic  hardening 
in  the  first  few  months  of  life,  the  very  warm  resorts  do  not  greatly  concern 
us.  Infants  past  the  age  of  three  months  do  not  require  an  afternoon  tem- 
perature averaging  more  than  65°  F.  (18°  C),  corresponding  to  that  of 
Boston  or  New  York  in  May;  this  figure  may  be  obtained  in  midwinter  in 
northern  Florida,  southern  California,  the  lowlands  of  Arizona,  and  Egypt. 
Children  who  are  beginning  to  run  about  do  better  at  a  temperature  some 


630  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

10°  F.  (6°  C.)  lower,  for  there  is  no  method  of  hardening  that  can  compare 
with  exposure  to  a  moderately  bracing  climate;  the  conditions  just  stated 
are  obtainable  in  winter  in  the  Carolina  lowlands,  northern  Georgia,  middle 
California,  southern  Italy,  and  the  Riviera.  All  these  regions  afford  ideal 
conditions  for  young  infants  in  early  spring,  for  it  is  inadvisable  to  take  a 
baby  that  has  wintered  in  the  south  to  such  a  climate  as  Cincinnati  or 
Philadelphia  before  the  middle  of  April,  or  to  Cliicago  or  Boston  before  May 
— ^the  change  from  warm  sunshine  to  cliilly  dampness  involves  great  risk. 
All  the  districts  so  far  mentioned  have  from  50  to  70  per  cent,  of  sunshine 
during  the  winter  months,  much  irregularity  of  temperature  in  the  south- 
eastern States,  a  great  difference  between  day  and  night  temperature  in 
Arizona  and  Egypt,  but  remarkably  even  thermometric  conditions  in  Cali- 
fornia and  southern  Europe. 

Similar  temperatures  would  be  desirable  in  summer,  but  there  are  no 
really  bracing  conditions,  readily  accessible,  on  our  side  of  the  Atlantic, 
except  on  the  north  Pacific  coast,  where  fogs  and  very  high  and  damp  winds 
prevail,  and  in  the  Canadian  Rocl^  Mountains.  For  very  young  infants  the 
middle  Atlantic  coast,  the  lowlands  of  interior  New  York  and  New  England, 
the  Lake  region,  and  the  south  California  coast  are  sufficiently  cool.  After 
the  first  summer  the  New  England  coast,  the  northern  Alleghanies,  the  cooler 
Roclvy  Mountain  points,  and  the  most  northerly  stations  on  the  Great  Lakes 
are  far  preferable.  Really  cool  summer  days,  averaging  well  below  70°  F. 
(21°  C.)  in  the  afternoon,  must  be  sought  in  the  mountains  of  central  Europe 
and  on  the  British  Isles;  the  American  continent  has  nothing  in  this  line  to 
offer  save  what  has  been  mentioned  at  the  commencement  of  this  paragraph. 

At  the  risk  of  becoming  wearisome  I  must  repeat  that  we  have  been  very 
remiss  in  not  paying  more  attention  to  the  value  of  change  of  climate  as  a 
means  of  hardening  young  children.  Exposure  to  a  moderately  low,  and 
therefore  bracing,  temperature  is  probably  the  best  tonic  at  our  disposal. 
It  will  be  observed  that  I  am  saying  nothing  about  the  subarctic  winter 
climate  of  the  Adirondack  Mountains  and  similar  regions.  I  omit  them  be- 
cause I  am  convinced  that  such  extreme  methods  are  certainly  not  required 
for  prophylaxis  against  tuberculosis,  although  they  are  occasionally  useful  in 
the  treatment  of  this  disease  in  older  children.  In  these  very  severe  climates 
young  children  are  kept  indoors  too  much  of  the  time  by  intense  cold  and 
heavy  snow-storms,  and,  unless  assiduous  care  is  taken,  or  even  in  spite  of  it, 
the  continuous  battle  with  very  low  temperatures  does  young  subjects  more 
harm  than  good.  At  these  early  ages  better  results  are  undoubtedly  to  l^e 
obtained  in  such  regions  as  North  Carolina,  Colorado,  or  New  Mexico. 

The  second  method  of  hardening  children,  usually,  but  undeservedly, 
regarded  as  the  best,  is  the  bath  in  its  various  forms.  I  regard  bathing  as 
somewhat  inferior  to  climatic  hardening  in  that  its  applicability  is  more 


HYGIENIC   AND    CLIMATIC   PROPHYLAXIS. — WACHENHEIM.  631 

limited,  and  because  its  proper  management  requires  far  more  skill  and  care  ; 
wisely  used,  however,  its  usefulness  cannot  be  disputed.  We  are  passing 
the  period  when  cold  bathing  was  advocated  for  all  ages,  including  infancy; 
nevertheless,  I  think  that  this  form  of  hardening,  hke  that  of  exposure  to 
the  weather  may  be  inaugurated  at  quite  an  early  period,  if  a  modicum 
of  common  sense  and  caution  be  employed. 

Hardening  by  means  of  the  daily  bath  may  be  achieved  somewhat  as 
follows:  The  temperature  of  the  water,  10°  F.  (38°  C.)  during  the  first  few 
months,  may  gradually  be  lowered  to  95°  F.  (35°  C.)  by  the  sixth  month,  and 
to  92°  F.  (33°  C.)  at  the  end  of  the  first  year.  In  the  course  of  the  second 
year  the  immersion  at  the  last-mentioned  temperature  may  be  followed  by 
a  brief  sponging  with  cooler  water,  the  temperature  of  which  is  gradually 
reduced  from  86°  to  77°  F.  (30°  to  25°  C). 

After  the  age  of  two  years  resort  may  be  had  to  daily  cool  sponging,  to 
be  carried  out  in  the  following  manner.  The  bath-room  should  have  a 
temperature  of  from  70°  to  72°  F.  (21°  to  22°  C),  and  the  child  should  stand 
in  water  of  about  92  °  F.  (33°  C.) ;  it  should  then  be  sponged  off  rapidly  with 
water,  at  the  same  temperature  to  begin  with,  lowering  it  to  about  77°  F. 
(25°  C.)  in  the  course  of  a  minute  or  two,  the  sponging  to  be  followed 
promptly  by  thorough  drying  with  a  rough,  and  preferably  warmed,  towel 
that  envelops  the  whole  body.  Within  a  j^ear  or  so  the  temperature  of  the 
sponging  water  may  be  reduced  to  68°  F.  (20°  C.)  without  harm,  but  lower 
temperatures  are  contraindicated,  for  they  often  seem  to  be  injurious,  even 
to  adults.  Cold  immersion  should  be  resorted  to  with  caution,  as  it  presup- 
poses considerable  robustness.  I  would  strongly  advise  against  it  before 
the  sixth  year,  and  then  begin  with  moderately  high  temperatures,  reserving 
those  near  68°  F.  (20°  C.)  for  puberty  and  beyond. 

It  is  not  easily  explained,  but  may  be  verified  by  any  one  on  his  own 
person,  that  cold  sea  or  river  "bathing  is  more  easily  borne  than  cold  tubbing. 
The  probable  reason  is  that  the  former  is  combined  with  a  certain  amount 
of  muscular  exercise,  as  in  swimming.  I  must  not  fail  to  mention  that  the 
test  of  reaction,  namely,  a  cutaneous  hyperemia  setting  in  after  a  minute  or 
so,  is  as  valuable  a  test  of  the  wholesomeness  of  cool  bathing  in  children  as 
in  adults.  In  infancy  and  the  earlier  years  of  childhood  the  reaction  is  not 
obtained  as  readily  as  later;  its  absence  is  an  infallible  sign  that  the  bath,  as 
given,  is  doing  harm,  and  higher  temperatures  should  be  resorted  to  at  once. 

Sea-bathing  is  an  invaluable  means  of  hardening  children,  but  can  hardly 
be  resorted  to  before  the  fourth  or  fifth  year,  owing  partly  to  the  cliild's 
dread  of  the  surf,  and  partly  on  account  of  actual  danger  on  coasts  subject 
to  strong  breakers  and  currents.  Another  difficulty  lies  in  the  circumstance 
that  the  sea  is  rather  cold  at  such  resorts  as  have  a  bracing  climate;  regions 
like  Long  Island  and  New  Jersey,  where  the  temperature  of  the  ocean  is 


632  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

just  right,  are  a  little  too  enervating  for  robust  children  beyond  the  age  of 
six  or  eight  years.  Fortunately,  such  relatively  delicate  children  as  call 
for  care  in  the  administration  of  sea  baths  also  require  a  slightly  warmer 
atmospheric  temperature.  The  best  way  to  surmount  the  cUfficulty  men- 
tioned is  to  take  the  child  to  a  rather  cool  climate,  and  shorten  the  time  for 
bathing,  in  extreme  cases  substituting  indoor  sea-water  baths  for  the  more 
strenuous  dips  in  the  ocean. 

When  the  ocean  temperature  is  about  60°  F.  (16°  C),  as  off  southern 
Maine,  middle  California,  the  coasts  of  Germany,  and  the  English  Channel, 
the  bath  should  last  only  a  minute  or  two.  A  tem.perature  of  65°  F.  (18°  C), 
as  off  Massachusetts,  southern  California,  and  in  the  Bay  of  Biscay,  permits 
an  immersion  of  from  three  to  five  minutes.  Long  Island  and  New  Jersey 
afford  water  temperatures  near  70°  F.  (21°  C),  and  allow  a  ten-minute 
bath  under  these  conditions.  In  the  still  warmer  waters  of  the  Mediter- 
ranean and  Chesapeake  Bay,  where,  however,  the  summer  climate  is  far  too 
warm  even  for  delicate  infants,  the  bath  may  last  still  longer.  The  common 
American  custom  of  permitting  children  to  stay  in  the  water  until  cyanosis 
develops  is  highly  reprehensible,  and  one  of  the  most  objectionable  methods 
of  hardening  known. 

Still-water  baths  require  slightly  higher  temperatures,  and  the  same  is 
true  of  fresh  water;  in  the  former  case  the  massage  of  the  breakers  is  absent, 
and  we  know  that  friction  is  almost  a  necessary  adjunct  to  cold  bathing. 
As  to  fresh-water  bathing,  it  is  well  known  that  a  salt  bath  feels  warmer 
than  one  in  pure  water  at  the  same  temperature;  the  saline  content  of  sea 
water  and  its  stimulation  of  the  sldn  are  the  determining  factors. 

Not  much  can  be  said  on  the  subject  of  clothing,  for  our  knowledge  of  its 
hygiene  is  still  imperfect.  Some  years  ago  wool  next  to  the  skin  was  deemed 
indispensable;  at  present  a  good  many  pediatricians  regard  it  as  altogether 
too  hampering,  preferring  loosely  woven  cotton  goods,  such  as  Canton  flannel 
and  stockinet.  It  is  well  to  note  that  some  children,  especially  infants,  have 
a  sldn  so  tender  as  to  be  greatly  irritated  by  the  jagged  fibers  of  wool;  the 
weaves  of  cotton  just  mentioned  do  not  cause  chafing.  With  the  customary 
overheating  of  American  houses,  a  rather  light  weight  of  clothing  should  be 
worn  indoors,  with  heavy  wraps  for  outdoor  use  in  the  cold  months.  The 
popular  fad  of  dressing  young  children  in  summer  so  that  they  are  seminude 
calls  for  the  sternest  condemnation.  It  is  difficult  to  understand  why  this 
fashion  has  been  applied  to  the  early  years  alone,  the  very  age  at  which  the 
body  is  less  sensitive  to  high  temperatures  than  later  on,  and  is  most  likely 
to  suffer  from  exposure  to  low  temperatures.  Holt*  very  properly  says  that 
permitting  children  to  run  about  with  bare  arms  and  legs,  even  in  midsum- 
mer, is  of  questionable  advantage,  even  in  our  Middle  States,  where  the 
*  Holt;  "Diseases  of  Infancy  and  Childhood." 


HYGIENIC   AND    CLIMATIC    PROPHYLAXIS. — WACHENHEIM.  633 

day  temperatures  are  rather  high,  though  considerable  coolness  may  often 
occur  in  the  early  morning,  and,  especially  at  the  seashore,  toward  evening 
also.  My  opinion  is  that  this  return  to  the  costume  of  barbarism  has  no 
value  except  to  facilitate  the  work  of  biting  insects.  Still  more  absurd  is 
the  idea  of  permitting  children  to  run  about  barefoot;  the  only  tangible 
result  of  this  practice  is  to  expose  the  child  to  the  risks  of  traumatism  in 
this  age  of  nails  and  broken  glass;  furthermore,  as  the  conventions  of  our 
civilization  call  for  a  return  to  shoes  and  stockings  in  later  years,  the  final 
utility  of  learning  to  go  barefoot  is  not  obvious.  Habits  that  must  eventually 
be  abandoned  are  hardly  worth  inculcating,  the  more  so  when  their  acquisition 
involves  risk  to  health  and  a  good  deal  of  discomfort. 

The  respective  tests  of  excess  or  insufficiency  of  clothing  are  simple,  sensi- 
ble perspiration  in  the  former  case,  cold  hands  and  feet  in  the  latter.  If  a  child 
suffers  from  coldness  of  the  extremities,  the  only  tiring  to  do  is  to  increase 
the  amount  of  clothing  or  supply  artificial  heat.  It  is  a  great  mistake  to 
expect  the  cliild  to  harden  itself  by  fighting  off  chilliness  through  metabolic 
stimulation  alone.  Much  harm  may  be  done  in  this  way,  for  prolonged  ex- 
posure to  low  temperatures  invariably  results  in  depression  of  the  vital 
functions,  and  the  cliild  finalty  becomes  what  we  call  "  delicate."  We  must, 
of  course,  take  care  not  to  go  to  the  opposite  extreme,  and  dress  children  too 
warmly  or  overheat  their  apartments,  as  enervation  is  quite  certain  to  fol- 
low. Errors  in  both  directions  are  committed  continually  nowadays,  so 
that  we  are  sometimes  led  to  wonder  if  parents  exercise  any  judgment  at 
all  in  tliis  important  matter.  It  is,  at  any  rate,  the  duty  of  the  family 
physician  to  inform  himself  about  this  matter  in  the  case  of  every  child 
under  his  care;  he  will  find  that  the  golden  mean  is  kept  in  the  fewest  families. 


Die  hygienische  und  klimatische  Prophylaxe  der  Tuberkulose  in  der 

Kindheit. — ^(Wachenheim.) 
Gute  allgemeine  Ernahrung  ist  eine  der  besten  Schutzwachen  gegen  die 
Tuberkulose  bei  Kindern.  Urn  diese  zu  sichern  haben  wir  Verdauungs- 
storungen  oder  nerv'ose  Appetitlosigkeit  zu  bekampfen.  Um  den  Appetit 
und  die  Verdauung  anzuregen,  ist  nichts  so  niitzlich  wie  korperliche  Ubung, 
vorzugsweise  im  Freien.  Wir  miissen  uns  erinnern,  dass  Uberanstrengung 
schiidlich  ist  und  sogar  priidisponirend  fi'ir  Tuberkulose  sein  kann.  Es  ist 
am  besten,  korperliche  tjbung  hauptsiichlich  als  eine  Abhiirtungsraethode 
zu  betrachten,  welche  ebensowohl  die  hauptsachlichste  Prophylaxe  als  auch 
Behandlung  der  Tuberkulose  ist.  In  der  Durchfi'ihrung  der  Abhiirtung 
sind  wir  sozusagen  auf  die  Anwendung  von  Kalte  beschrankt.  Kalte  frische 
Luft  rangirt  zuerst  unter  unseren  Abhartungsmassnahmen,  dann  kalte 
Bader;  beide  miissen   vorsichtig  angewendet  werden,  besonders  bei  sehr 


634  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

jungen  Kindern,  mit  nach  unci  nach  anwachsender  Starke,  wie  das  Kind 
alter  wird,  da  Excesse  in  dieser  Richtung  auch  schadlich  sind.  Wo  das 
vaterlandische  Klima  des  Kindes  geniigenden  Aiifenthalt  im  Freien  aus- 
schliesst,  soil  eine  mildere  Gegend  gesucht  werden,  wobei  man  achtgeben  soil, 
nicht  durch  zu  hohe  Temperatur  eine  Nervenabspannimg  zu  veriirsachen. 

In  Bezug  auf  das  kalte  Baden  sollte  damit  nicht  im  Saiiglingsalter  be- 
gonnen  werden.  In  der  spiiteren  Kindheit  sind  Seebader  von  besonderem 
tonischen  Werte.  Die  Abhartung  durch  gut  regulirte  Kleidung  befindet 
sich  noch  im  Versuchsstadium ;  individuelle  Idiosynkrasie  ist  noch  immer 
vmser  leitende  Gedanke,  aber  Absurditiiten  wie  halbe  Nacktheit  sollten  ver- 
worfen  werden.  Wir  bestimmen  bei  Kindern,  dass  die  Kleidung  geniigend 
sei,  dadurch  dass  wir  die  Temperatur  ihrer  Extremitaten  wahrnehmen, 
da  tJberhitzung  zum  mindesten  ebenso  schadlich  ist  als  Frost. 


La  Profilaxis  de  la  Tuberculosis,  Higienica  y  Climatologica,  en  la  Ninez, 

— (Wachenheim.) 
Una  buena  nutricion  general  es  uno  de  los  mejores  salva-guardia  contra 
la  tuberculosis  en  la  niiiez;  a  fin  de  conseguir  esta  uno  tiene  a  raenudo 
necesidad  de  combatir  los  desarreglos  de  la  digestion  6  los  desganos  de 
origen  neurotico.  Para  estimular  el  apetito  y  la  digestion,  nada  es  mas 
util  como  el  ejercicio,  con  preferencia  el  ejercicio  al  aire  lib  re;  debe  tenerse 
en  cuenta  sinembargo  que,  el  ejercicio  exesivo  es  danoso  y  que  6ste  aun 
puede  predisponer  a  la  tuberculosis;  el  ejercicio  debera  mas  bien  consider- 
arse  como  el  mejor  metodo  de  fortificacion  del  cuerpo  que  es  la  profilaxis 
soberana  y  tambien  el  mejor  tratamiento  de  la  tuberculosis.  En  la  fortifica- 
cion del  cuerpo  uno  esta  practicamente  limitado  a  la  aplicaci6n  del  frio,  el  aire 
libre  frio  ocupa  el  primer  rango,  entre  nosotros,  como  uno  de  los  mejores  medios 
en  la  fortificacion  del  cuerpo,  y  los  banos  frios  pueden  considerarse  como  se- 
gundos  en  importancia,  ambos  sinembargo  deberan  aplicarse  gradualmente, 
especialmente  en  la  ninez,  aumentandolos  en  proporcion  a  la  edad  del  niiio; 
el  exceso  es  danoso.  Si  el  clima  nativo  del  niilo  previene  suficiente  ejercicio 
al  aire  libre,  un  clima  mas  natural  debera  buscarse,  teniendo  cuidado  de  no 
ocasionar  enervacion  debida  a  la  temperatura  excesiva.  Con  relacion  a 
los  banos  frios,  estos  no  deberan  ser  aplicados  en  la  infancia,  y  mas  tarde 
en  la  ninez  los  banos  de  mar  son  de  un  tonico  valioso.  La  fortificaci6n  del 
cuerpo  por  m^dio  de  la  regularizacion  apropiada  en  el  vestido,  esta  todavia  en 
un  estado  empirico  y  la  idiosincrasia  individual  deberd  conciderarse  como 
la  mejor  guia  en  este  punto,  absurdidades  tales  como  media  desnudez  debe 
condenarse,  nosotros  regulamos  el  vestido  apropiado  en  los  niiios  por  medio 
de  la  temperatura  de  la  extremidades,  exesivo  calor  es  a  lo  menos  tan  daiioso 
como  el  frfo  exesivo. 


OVERCOMING     THE     PREDISPOSITION    TO    TUBER- 
CULOSIS  AND   THE   DANGER   FROM   INFECTION 
DURING  CHILDHOOD. 

By  S.  Adolphus  Knopf,  M.D., 

Professor  of  Phthisiotherapy  at  the  New  York  Post-graduate  Medical  School  and  Hospital. 


That  there  may  occasionally  be  a  direct  bacillary  transmission  from  the 
tuberculous  parent  to  the  child  has  been  demonstrated  sufficiently  to  permit 
of  no  further  dispute.  Yet  the  number  of  such  cases  is  insignificant,  com- 
pared with  the  frequency  with  wliich  a  predisposition  to  tuberculosis  in 
particular,  and  to  other  diseases  in  general,  is  transmitted  to  the  offspring  of  a 
tuberculous  mother  or  father.  That  this  predisposition  leads  so  frequently  to 
the  development  of  a  tuberculous  disease  can,  of  course,  be  easily  accounted 
for  by  the  many  opportunities  the  child  has  of  acquiring  a  post-natal  in- 
fection as  a  result  of  the  tuberculous  environment  in  which  it  is  forced  to 
live.  The  exposure  to  infection  is,  of  course,  greatest  when  the  mother  is 
tuberculous. 

In  the  second  portion  of  this  paper  we  will  enter  more  fully  into  the 
details  of  exposure  to  post-natal  infection  during  childhood.  For  the  present 
we  will  devote  our  attention  to  overcoming  the  predisposition  inherited  from 
a  tuberculous  parent. 

In  what  does  this  predisposition  consist?  It  is  a  general  enfeebled  con- 
dition without  a  distinct  pathological  lesion,  all  the  organs  possessing  per- 
haps less  than  the  normal  resisting  power  to  the  invasion  of  any  disease.  I 
believe  the  words  "physiological  poverty"  will  express  more  clearly  than 
any  others  the  condition  of  a  child  with  a  predisposition  to  tuberculosis  and 
other  diseases  inherited  from  father  or  mother. 

The  child  of  a  tuberculous  mother,  conceived  and  born  while  the  mother 
is  suffering  with  pulmonary  tuberculosis  in  the  advanced  stages,  has,  of 
course,  poorer  chances  for  life  and  health  than  in  those  cases  in  wliich  con- 
ception takes  place  in  the  incipient  stage  of  the  mother's  disease.  When  both 
parents  were  tuberculous  at  the  time  of  the  conception  of  the  child,  the  off- 
spring is  naturally  more  strongly  predisposed  to  contracting  tuberculosis. 
The  predisposition  is  usually  least  marked  in  the  earlier  years  of  childhood 
when  the  mother  was  healthy  and  only  the  father  tuberculous  at  the  time 
of  conception. 

635 


636  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

But  whether  the  father  or  the  mother  is  the  tuberculous  parent,  or 
whether  the  progenitors  have  been  in  the  earUer  or  later  stages  of  the  disease, 
the  attempt  to  overcome  the  predisposition  to  tuloerculosis  in  infancy  and 
childhood  must  begin  with  the  child  in  utero.  The  mother  who  fears  the 
transmission  of  a  tuberculous  predisposition  to  her  child  must,  throughout 
the  child-bearing  period,  live  in  the  best  possible  hygienic  environment,  in 
the  purest  air  obtainable,  and,  from  the  earliest  recognition  of  her  condition, 
refrain  from  the  use  of  constricting  garments.  She  should  breathe  deeply 
and  often;  in  fact,  she  should  take  regular  breathing  exercises  until  the 
desire  for  deep  breathing  becomes  natural  to  her.  The  Idnd  of  breathing 
exercises  that  a  pregnant  woman  can  take  without  fear  of  harm,  but  wliich, 
on  the  contrary,  will  benefit  her,  are  the  following :  She  takes  a  deep  inhala- 
tion, and  during  this  act  raises  her  shoulders,  rolls  them  backward,  and  holds 
the  breath  for  three  or  five  seconds  while  in  this  position.  Then  she  exhales 
while  moving  the  shoulders  forward  and  downward.  This  exercise,  which 
she  can  take  from  three  to  five  times  every  half-hour,  should,  of  course,  be 
practised  only  in  pure  air,  preferably  near  the  open  window  or  out  of  doors. 

The  subject  of  respiratory  exercises  will  be  discussed  more  fully  further 
on,  but  it  is  interesting  to  note  here  the  benefit  that  the  lungs  of  the  mother 
of  the  future  child  derive  from  deep  breathing.  Under  ordinary  conditions 
we  never  inhale  or  exhale  more  than  about  500  c.c.  of  air,  which  represents 
the  tidal  volume,  or  tidal  air.  When  we  inhale  deeply,  we  are  able  to  take 
in  1500  c.c.  of  air  (complemental  volume,  or  complemental  air),  and  about 
the  same  amount  of  supplemental  or  reserve  air  can  be  expelled  by  making 
the  expiratory  exercises  correspond  in  effort  to  the  inspiratory  exercises, 
It  must  be  evident  that  not  only  the  respiratory,  but  also  the  circulatory 
system — in  fact,  the  whole  system — must  be  benefited  by  the  practice  of 
deep  breathing. 

The  living  and  the  sleeping  room  of  the  pregnant  woman  should  always 
be  well  ventilated,  and  at  least  one  window  should  be  kept  open  in  the  bed- 
room, even  in  cold  weather.  While  it  is  hard  to  demonstrate  that  the  fear 
so  many  people  have  of  night  air  is  indirectly  responsible  for  a  good  deal  of 
tuberculosis,  I  believe,  nevertheless,  this  to  be  the  case.  Some  people  will 
sleep  in  a  small  bedroom,  often  together  with  several  other  individuals,  with 
windows  tightly  closed,  breathing  the  same  air  over  and  over  again,  and  thus 
surely  poisoning  themselves  with  the  toxic  products  of  their  own  exhalation 
and  that  of  the  other  sleepers. 

It  is  difficult  to  write  on  the  subject  of  tuberculosis  of  childhood  without 
touching  upon  the  social  problem.  How  can  the  pregnant  woman,  obliged 
to  labor  in  a  factory  or  workshop,  often  until  the  last  few  hours  before  her 
confinement,  carry  out  the  hygienic  instructions  just  given,  wliich  she  should 
do  in  order  to  bear  a  child  vigorous  and  strong,  with  sufficient  natural  re- 


OVERCOmNG    PREDISPOSITION    AND   INFECTION. — KNOPF.  637 

sisting  power  never  to  contract  tuberculosis.  There  should  be  a  law  pro- 
hibitmg  work  in  unsanitary,  dusty,  and  badly  ventilated  environments  for 
all  persons,  but  more  particularly  for  women  and  children.  The  pregnant 
woman  should  be  obliged  to  cease  work  in  a  factory  or  workshop  two  months 
before  her  confinement,  and  not  be  permitted  to  reenter  until  one  month 
after  confinement  and  complete  restoration  to  health. 

A  typical  description  of  such  conditions,  where  pregnant  women  work 
until  the  very  last  moment  in  factories,  can  be  found  in  Mr.  John  Spargo's 
book,  "The  Bitter  Cry  of  the  Children."  Unfortunately,  poverty  compels 
them  not  infrequently  to  adopt  most  pitiful  means  to  hide  their  condition, 
so  that  they  may  not  be  discharged.  Perhaps  they  no  not  fear  so  much  the 
few  weeks  of  absence  which  their  condition  demands:  what  they  fear  most 
is  permanent  cHscharge — "losing  the  job,"  and  then  being  obliged  to  hunt 
for  another.  But,  as  Mr.  Spargo  very  tersely  puts  it,  "The  consequences  are 
too  serious  aUke  to  mother  and  child  to  justify  legislative  neglect." 

Here  is  a  field  for  the  exercise  of  the  greatest  humanitarian  consideration 
on  the  part  of  the  employer,  and  the  philanthropists  who  will  create  an  in- 
stitution destined  to  succour,  during  a  few  months  after  childbirth,  any 
family  depencUng  also  upon  the  mother's  earnings,  can  rest  assured  that 
many  a  life  will  thereby  be  saved. 

The  newly  born  child  is  as  much  in  need  of  pure  air  as  the  adult,  and 
while  in  early  infant  hfe  the  system  requires  more  warmth,  the  air  the  cliild 
is  to  breathe  must  be  pure  and  free  from  dust  and  other  impurities.  The 
]ying-in  rooms  and  nursery  should  be  well  ventilated,  and  their  temperature 
suitably  regulated.  The  atmosphere  in  such  rooms  should  be  warm  enough, 
but  never  too  hot  nor  too  dry. 

As  the  child  grows  older  it  should  gradually  be  accustomed  to  cooler 
air.  The  custom  of  enveloping  the  child's  face  in  a  thick  veil  when  it  is 
taken  for  an  airing  is  absurd,  and  if  veiling  is  used  at  all,  it  should  be  thin, 
permitting  the  air  to  have  access  to  the  face.  As  the  child  grows  older  it 
should  be  noted  whether  proper  breathing  through  the  nose  occurs,  or 
whether  the  nose  seems  to  be  obstructed,  and  breathing  performed  with  the 
mouth  open.  It  must  be  remembered  that  mouth-breathing  in  children  is  a 
predisposing  cause  to  frequent  colds,  to  bronchitis,  and  to  similar  affections, 
all  of  which,  in  many  instances,  must  be  considered  as  forerunners  of  con- 
sumption. Mouth-breathing  in  children  is  caused,  as  a  rule,  by  growths  in 
the  throat  (adenoid  vegetations),  and  sometimes  by  enlarged  tonsils  or  by 
polypi  in  the  nose.  Besides  the  deleterious  influence  on  the  child's  respira- 
tory system,  adenoid  vegetations  may  also  give  rise  to  difficulty  of  hearing, 
consequent  impairment  of  the  intellect,  and  even  to  actual  deformities  of  the 
jaw.  Adenoids  and  all  other  obstructions  to  free  breathing  should  be 
promptly  removed  by  operation. 


638 


SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 


When  a  child,  because  of  its  delicate  constitution,  is  susceptible  to  fre- 
quent colds,  so  that  the  mother  may  hesitate  to  take  it  outdoors  often  enough, 
she  should  be  told  that  fresh,  pure  air  never  in  reality  gives  rise  to  colds,  but 
that  what  is  commonly  known  as  a  cold  is  often  an  infectious  disease,  due  to  a 
specific  microorganism  that  fastens  itself  more  readily  on  a  delicate  system. 
Such  so-called  susceptibility  to  colds  may  be  overcome  by  the  judicious  use 
of  cold  water. 

From  the  tenth  to  the  twelfth  month  one  should  accustom  the  cliild 
gradually  to  cold  baths.  The  best  time  to  begin  is  after  its  daily  warm  bath. 
Rub  the  child  a  few  times  with  the  hands  dipped  in  cold  water,  and  then 
wdpe  it  rapidly.  Later  one  may  begin  with  cold  sponging,  and  still  later 
with  a  little  douche.  It  is  absolutely  necessary,  when  using  cold  water,  that 
the  reaction  should  follow  rapidly.     This  reaction,  as  is  well  known,  is  mani- 


Fig.    1. — Situation    of  Fig.    2. — Lungs,  liver,  Fig.    3. — Skeleton    of    a 

organs  in  chest    and   ab-       and  intestines  in  a  thorax       chest     depressed     by     tight 
domen  in  a  normal  thorax.       constricted  by  tight  lacing.      lacing. 


fested  by  a  pleasant  warmth  perceived  by  the  child,  and  externally  by  a 
reddish  appearance  of  the  skin.  When  cold  water  is  applied  to  the  skin, 
there  occurs  at  first  a  certain  whiteness  or  pallor,  caused  by  contraction  of 
the  external  blood-vessels.  The  return  of  the  blood  to  the  external  surface 
produces  the  reddening  of  the  skin.  Whenever  reaction  is  absent  or  tardy, 
the  advice  of  a  physician  should  be  sought. 

It  is  important  that  a  child  should  always  be  properly  dressed.  In  order 
that  its  lungs  may  develop  to  the  fullest  extent,  no  restricting  garments 
must  be  worn,  and  this  applies  in  particular  to  tight  neckwear,  such  as  con- 
stricting collars  and  bands.  Furthermore,  it  must  be  remembered  that 
when  the  neck  is  too  closely  muffled,  the  resisting  powers  to  cold  are  lessened, 
and  the  child  becomes  susceptible  to  colds  whenever  a  change  in  the  atmos- 
phere occurs. 

When  a  girl  develops  into  a  young  woman,  she  should  be  told  that  the 


OVERCOMING   PREDISPOSITION   AND   INFECTION. — KNOPF. 


639 


tightly  laced  corset  is  one  of  the  most  injurious  garments  that  can  be  worn, 
not  only  interfering  with  free  and  natural  breathing,  but  giving  rise  to  in- 
digestion and  disturbances  of  the  circulation  as  well.  The  anemia  so  often 
observed  in  young  girls  can  very  frequently  be  ascribed  to  this  same  cause, 
which  does  not  permit  either  a  free  circulation  or  sufficient  oxygenation  of 
the  blood. 

The  illustrations  show  the  result  of  tight  lacing.  Fig.  1  shows  the  situ- 
ation of  the  organs  in  chest  and  abdomen  in  a  normal  thorax.  Fig.  2  shows 
lungs,  liver,  and   intestines  as  they  appear  in    a   thorax  constricted  by 


T-I ._-^ 


Fig.  4. — Respiratory  exerci.se  A:  raising  of  hands  to  horizontal. 


wearing  a  tightly  laced  corset  for  a  numljer  of  years.     Fig.  3  shows  the 
skeleton  of  a  chest  deformed  by  tight  lacing. 

As  soon  as  the  intelligence  of  the  growing  child  will  permit,  it  should  be 
taught  to  breathe  deeply,  and  later  on  to  take  the  following  breathing  exer- 
cises; standing  in  front  of  an  open  window  or  out  of  doors,  the  child  should 
assume  the  position  of  military  "attention,"  with  heels  together,  l)odv erect, 
and  hands  at  the  sides.  With  the  mouth  clcsed  it  takes  a  deep  inspiration, 
breathing  in  all  the  air  possible,  and  while  doing  so  raises  the  arms  to  a 
horizontal  position  (Fig.  4),  holding  the  air  inhaled  for  from  four  to  five 


640 


SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 


seconds,  and  while  exhaling  (breathing  out),  brings  the  arms  down  to  the 
original  position.  The  act  of  exhaling,  or  expiration,  should  be  done  a  little 
more  rapidly  than  the  act  of  inspiration,  the  former  consuming  about  three 
seconds,  while  the  latter  occupies  about  four.  As  previously  stated,  the  air 
inspired  should  be  retained  for  about  five  seconds.  The  child  should  be 
taught  to  count  mentally  during  these  three  acts,  so  as  to  be  systematic 


-^       ^^'^^  - 


Fig.  5. — Respiratory  ex- 
ercise B:  to  expand  the  chest 
laterally. 


Fig.  6. — Respiratory 
exercise  C:  with  hands 
above  the  head  and  back- 
ward movement. 


Fig.  7. — Respiratory 
exercise  D:  for  combined 
abdominal  and  chest 
breathing. 


about  holding  the  air;  one  can  give  two  upward  and  two  downward  move- 
ments of  the  wrist-joints,  counting  four,  and  at  the  fifth  second  lower  the 
arms  and  begin  to  exhale. 

When  exercise  A  is  thoroughly  mastered,  exercise  B  may  be  undertaken. 
The  arms  are  placed  one  above  the  other  in  front  of  the  chest,  giving  the  hands 
a  position  as  though  about  to  tear  open  the  chest  (Fig.  5).     Then  hands,  arms. 


OVERCOMIXG    PREDISPOSITION   AND   INFECTION. — KNOPF.  641 

and  shoulders  make  a  baclovard  movement  (the  fingers  remaining  Ijent), 
during  which  a  deep  inspiration  is  taken.  Again  counting  four  by  tapping 
the  chest  four  times  with  both  hands,  at  the  fifth  second  one  starts  to  exhale, 
bringing  the  hands  and  forearms  back  into  the  position  they  held  when  start- 
ing. This  exercise  has  the  advantage  that  it  can  be  taken  in  the  sitting 
position  or  even  when  lying  down  on  the  back. 

The  third  exercise,  C,  consists  in  raising  the  arms  from  the  sides  to  the 
horizontal  and  then  above  the  head  (Fig.  6),  taking  a  deep  mspiration  during 
this  act,  then  bending  backward  as  far  as  one  can,  and  remaining  in  that 
position  for  four  seconds  while  retaining  the  air,  counting  the  seconds  by 
moving  the  hands  alternately,  tmce  forward  and  twice  backward,  and  at 
the  fifth  second  exhaling  gradually  while  resuming  the  original  position. 
During  this  exercise  it  should  be  borne  in  mind  that  when  the  arms  are  raised 
until  the  hands  join,  one  should  not  bring  the  arms  close  to  the  head,  but 
rather  form  a  circle  above  the  head  by  bending  the  arms  forward  far  enough 
so  that  the  meeting  of  the  index-fingers  and  thumbs  forms  a  triangle. 

Exercise  D  is  intended  to  bring  the  abdominal  muscles  also  into  play,  or, 
in  other  words,  to  combine  abdominal  and  chest  breathing.  To  this  end 
the  erect  position  is  assumed,  as  at  the  beginning  of  all  the  exercises,  \\ith 
the  hands  meeting  in  front,  and  the  little  fingers  and  the  edge  of  the  palms 
touching  the  abdominal  muscles  (Fig.  7).  Taking  a  deep  inspiration,  raise 
the  diaphragm,  concentrating  all  attention  on  this  act,  and  while  doing  so 
move  the  joined  hands  upward,  sliding  them  along  the  thorax  up  to  the  chin; 
then,  turning  them,  continue  to  raise  them  until  they  are  above  the  head, 
as  in  Fig.  6.  Bend  backward  during  the  four  seconds  while  retaining  the  air, 
and  then  exhale,  lowering  the  arms  gradually  to  the  horizontal  and  to  the 
original  position  of  "attention." 

The  fifth  breathing  or  respiratory  exercise,  E,  which  may  also  be  called 
a  dr}^  swim,  requires  more  strength  and  endurance.  It  should  not  be  under- 
taken until  the  other  exercises  have  been  practised  regularly  several  times 
a  day  for  a  few  weeks,  and  until  an  evident  improvement  in  breathing  and 
general  well-being  has  been  observed.  One  takes  the  usual  military  position 
of  "attention,"  and  then  stretches  the  arms  out  as  if  in  the  act  of  swimming 
(Fig.  8),  the  backs  of  the  hands  toucliing  each  other.  During  the  inspira- 
tion the  arms  are  moved  outward  until  they  finally  meet  behind  the  back, 
remaining  in  this  position  for  the  usual  four  seconds,  counting  by  moving  the 
hands  while  retaining  the  air,  and  at  the  fifth  exhale,  bringing  the  arms 
forward  again,  ready  to  start  for  another  swim;  or  if  this  is  the  end  of  the 
dry  swim,  the  arms  return  to  the  original  position  of  "attention." 

This  somewhat  difficult  exercise  can  be  facilitated  and  rendered  more 
effective  by  rising  on  the  toes  during  the  act  of  inhalation  and  descencUng 
during  the  act  of  expiration. 

VOL.   II — 21 


642 


SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 


It  will  be  seen  that  with  the  aid  of  these  five  respiratory  exercises  every 
part  of  the  body,  from  the  nostrils  down  to  the  toes,  is  brought  into  play. 
The  face  alone  is  at  rest,  and  can  serve  as  an  indicator  that  the  exercises  are 
properly  done,  for  it  must  be  borne  in  mind  that  they  must  be  taken  with 
the  muscular  system  relaxed,  and  all  unnecessary  contraction  of  the  muscles 
or  tremor-like  movements  must  be  avoided. 

One  cannot,  of  course,  when  out  of  doors,  always  take  these  exercises 
with  the  movement  of  the  arms  without  attracting  attention.     Under  such 


Fig.  8. — Respiratory  exercise   E:    swim-      Fig.  9. — Respiratory   exercise   F:  raising 
ming  motion.  of  shoulders  upward  and  downward. 


conditions  one  quietly  assumes  a  position  similar  to  "attention,"  raises  the 
shoulders,  making  a  rotary  movement  during  the  act  of  inhaUng  (Fig.  9), 
remains  in  this  position,  holding  the  breath  for  four  seconds,  and  then 
exhales,  while  moving  the  shoulders  forward  and  downward,  assuming  again 
the  normal  position.  This  exercise,  F,  can  be  easily  taken  while  walking, 
sitting,  or  riding  in  the  open  air. 

Young  girls  and  boys,  and  especially  those  who  are  predisposed  to  tuber- 
culosis, often  acquire  the  habit  of  stooping.  To  overcome  this,  the  following 
exercise,  G,  is  to  be  recommended.    The  child  makes  his  best  effort  to  stand 


OVERCOAUNG    PREDISPOSITION   AND   INFECTION. — KNOPF. 


643 


straight,  places  his  hands  on  his  hips,  with  the  thumbs  in  front,  and  then 
bends  slowly  backward  as  far  as  he  can  during  the  act  of  inhaling  (Fig.  10). 
He  remains  in  this  position  for  from  four  to  five  seconds,  while  holding  the 
breath,  and  then  rises  again  somewhat  more  rapidly  during  the  act  of  ex- 
halation, assuming  the  original  position,  with  hands  on  hips. 

The  following  general  rule  concerning  breathing  exercises  should  always 
be  remembered:  Commence  with  the  easier  exercises  (A),  and  when  these 
are  completely  mastered,  proceed  to  the  more  difficult  ones.    Take  from  four 


Fig.   10. — Respiratory  exercise  G: 
overcome  stooping  position. 


to 


Fig.  11. — Respiratory  exercise  H: 
showing  the  second  forced  exhalatory 
movement. 


to  six  respiratory  exercises  (one  of  A,  B,  C,  D,  E,  or  F),  or  when  outdoors 
simply  exercise  F,  four  to  six  times  every  half-hour  or  hour,  or  at  least  four 
to  six  times  a  day,  and  on  rising  in  the  morning  and  on  retiring  at  night. 
Continue  this  practice  until  deep  breathing  has  become  a  natural  habit. 
These  exercises  should  always  be  taken  in  an  atmosphere  as  fresh  and  as  free 
from  dust  as  possible.  Never  take  these  breathing  exercises  when  tired, 
and  never  continue  them  to  the  point  of  exhaustion. 

These  exercises  are  intended  for  children  who  are  not  as  yet  tuberculous, 


644  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

and  while  I  believe  them  to  beof  incalculable  benefit  as  a  means  of  helping  a 
child  to  overcome  a  predisposition  to  tuberculosis,  they  can  do  harm  if  the 
child  is  very  delicate  and  if  not  administered  judiciously.  If  not  carried  to 
excess,  they  will  never  be  harmful  to  the  healthy  child.  These  breathing 
exercises  should  be  made  a  regular  and  frequent  part  of  the  day's  work  in 
all  schools. 

As  an  additional  means  of  developing  the  lungs  of  children,  particularly 
school-children,  we  cannot  too  strongly  recommend  the  frequent  practice  of 
singing  and  recitation  in  the  open  air.  Barth  in  Koslin,  Germany,  has  made 
a  careful  study  of  the  effects  of  singing  on  the  action  of  the  lungs  and  heart, 
on  diseases  of  the  heart,  on  the  pulmonary  circulation,  on  the  blood,  on  the 
vocal  apparatus,  the  upper  air-passages,  the  ear,  the  general  health,  the 
development  of  the  chest,  on  metabolism,  and  on  the  activity  of  the  diges- 
tive organs,  and  has  come  to  the  conclusion  that  singing  is  one  of  the  exer- 
cises most  conducive  to  health.  Considering  the  fact  that  it  can  be  practised 
everywhere  where  the  air  is  pure  or  at  any  time,  without  apparatus,  it  should 
be  much  more  cultivated  than  it  actually  is.  The  German  military  authori- 
ties, which  have  the  reputation  for  instituting  all  exercises  which  tend  to 
invigorate  the  soldiers,  have  of  late  years  encouraged  singing  during  marches 
of  all  troops.  Visits  to  zoological  gardens,  botanizing  tours,  geological  ex- 
cursions, and  mountain  climbing  should  form  an  important  part  of  the  curri- 
culum throughout  school  life.  They  will  tend  to  develop  the  pupils'  physique 
and  strengthen  its  resisting  power  to  the  invasion  of  the  tubercle  bacilli. 
These  outdoor  instructions  should  not  be  limited  to  the  summer  season  only. 

After  having  mastered  all  the  exercises  just  described,  there  is  one  which, 
for  the  older  cMld  particularly,  will  help  to  develop  his  chest.  This  is  exer- 
cise H,  and  is  practised  in  the  following  way:  he  takes  the  usual  position  of 
''attention,"  then  inhales  deeply,  rolling  the  shoulders  upward  and  back- 
ward, holding  the  air  for  four  seconds,  as  in  exercise  F  (Fig.  9),  and  at  the 
fifth  second  exhales  all  he  possibly  can,  again  resuming  the  original  position, 
but  before  again  inhaling  makes  a  second  expiratory  effort  while  turning  his 
arms  outward  (movement  of  supination)  and  pressing  the  inner  side  of  the 
upper  arms  against  the  chest  (Fig.  11).  He  thus,  so  to  speak,  squeezes  out 
all  the  air  there  is  left  in  the  lungs.  A  vacuum  in  the  lungs  is  created,  and 
the  subject  involuntarily  takes  a  very  deep  inhalation,  after  that  assuming 
the  ordinary  quiet  position  of  "attention." 

To  demonstrate  the  value  of  this  exercise,  let  me  again  repeat  here  that 
during  ordinary  inhalation  and  exhalation,  that  is  to  say,  quiet  respiration, 
the  amount  of  tidal  air  inhaled  is  only  500  c.c. ;  the  volume  that  can  be  inhaled 
by  the  first  exercise  is  1500  c.c,  and  the  volume  that  can  be  exhaled  by 
this  exercise  is  about  1300  c.c.  When,  now,  by  the  second  expiratory 
effort,  aided  by  the  supination  of  the  arms  and  pressure  against  the  chest, 


I 


OVERCOMING    PREDISPOSITION    AND   INFECTION. — KNOPF.  645 

500  c.c.  more  of  reserve  or  residual  air  can  be  expelled,  the  value  of  this 
exercise,  taken  before  going  to  work,  at  recess,  and  on  return  from  work,  or 
whenever  one  is  surrounded  by  fresh,  pure  air,  must  be  evident. 

The  fact  that,  in  the  majority  of  cases,  the  tuberculous  process  begins 
at  the  apices  has  been  explained  by  the  supposed  faulty  inspiratory  function 
of  this  part  of  the  lungs.  I  agree  in  tliis  respect  with  Hanau,*  and  consider 
the  almost  universally  adopted  statement  of  the  deficient  inspiratory  func- 
tion of  the  apices  erroneous.  On  the  contrary,  these  portions  of  the  lungs 
inspire  exceedingly  well — in  fact,  almost  too  well,  for  dust  and  micro- 
organisms enter  there  most  easily  and  are  found  in  large  quantities  in  careful 
post-mortem  examinations.  What  is  faulty  is  the  expiratory  function  of 
the  apices.  A  thorough  exhalation,  followed  by  a  forced  expiratory  effort, 
as  just  described,  is,  to  my  mind,  the  only  possible  way  to  improve  this  de- 
fect and  prevent  stagnation  and  congestion. 

If  any  argument  were  needed  to  prove  the  value  of  a  well-developed  chest 
and  deep  frequent  respiration  of  good,  pure  air,  confirmation  could  be  had 
from  a  reference  to  the  statistics  that  prove  that  all  mountaineers  have 
deep,  well-developed  chests,  and  are  the  most  immune  of  all  people  to  tuber- 
culosis. While,  of  course,  the  fact  that  mountaineers  live,  as  a  rule,  in  less 
crowded  regions,  must  be  taken  into  consideration,  there  is  no  doubt  that 
their  wonderful  chest  development  is  one  of  the  principal  reasons  for  their 
relative  immunity  from  tuberculosis.  This  immunity  is  due  to  the  physio- 
logical effect  on  the  human  body  of  liigh  altitudes.  The  circulation  is  slower, 
often  below  the  normal  in  those  living  constantly  in  the  mountains,  and 
their  breathing  is  deeper,  the  inspiration  longer,  and  the  expiration  more 
complete. 

In  order  to  give  the  child  the  greatest  possible  opportunity  to  breathe 
fresh,  pure  air  and  the  best  chances  for  physical  development,  other  factors 
than  those  just  described  must  be  brought  into  play.  First,  the  child  must 
have  more  years  of  play.  A  child  should  not  be  sent  to  school  before  its 
eighth  year.  It  should  have  more  hours  of  sleep  than  most  children  have, 
and  child  labor  should  be  abolished.  More  playgi'ounds  should  be  estab- 
lished. Every  roof  of  a  tenement-house  should  be  transformed  into  a  play- 
ground. With  the  help  of  strong  wire  fencing  and  awnings  such  a  roof- 
garden  could  be  utilized  the  gi-eater  part  of  the  year  for  cliildren  of  all 
ages. 

Cliildren's  school  farms,  such  as  are  conducted  in  New  York,  should  be 
established  in  all  large  and  small  cities.  Such  a  farm,  particularly  when 
located  in  a  congested  district,  does  both  preventive  and  constructive  work. 

Outdoor  games  and  athletic  sports  should  be  encouraged  everywhere  in 

♦Hanau,  A.:  "Beitriige  zur  Pathologie  der  Lungenkrankheiten,"  Zeit.  f.  klin. 
Med.,  xii,  1887. 


646  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

children's  schools,  and  should  not  be  limited  to  the  male  sex  alone,  and  par- 
ticularly not  during  adolescent  life. 

When  a  predisposition  has  seemingly  been  overcome,  and  the  child  leaves 
school,  it  is  well  to  bear  in  mind  the  possibility  of  a  relapse  into  such  a  con- 
dition through  an  unwise  choice  of  profession  or  calling.  An  occupation  or 
a  profession  demanding  a  sedentary  life  and  exposing  the  individual  to  the 
inhalation  of  vitiated  air  and  dust  is  unsuited  for  any  one  who  is  or  was  at 
one  time  predisposed  to  tuberculosis. 

Concerning  the  prevention  of  post-natal  infection  we  must,  first  of  all 
prohibit  the  tuberculous  mother  from  nursing  her  cliild,  and,  secondly,  see 
that  the  artificially  fed  child  is  provided  with  milk  that  is  absolutely  pure 
and  free  from  tuberculous  germs  and  other  pathogenic  microorganisms. 

The  most  frequent  sources  of  post-natal  infection  are,  perhaps,  the  follow- 
ing. A  tuberculous  mother  or  nurse  caresses  the  child  and  kisses  it  on  the 
mouth.  Or,  while  carr3'ing  the  child  in  her  arms,  she  coughs,  and  a  drop  in- 
fection from  a  bacilliferous  spray  ensues.  Or  she  prepares  the  food,  tasting 
it  to  judge  its  temperature  and  flavor  thi'ough  the  same  rubber  nipple  or 
with  the  same  spoon  the  child  uses,  and  thus  unconsciously  conveys  the 
germs  of  the  disease  from  her  own  mouth  to  that  of  the  cliild.  As  the  child 
grows  older  it  will  play  on  the  floor  of  the  room,  and  if  there  be  a  tuberculous 
subject  in  the  family,  the  child  is,  indeed,  likely  to  become  infected  with  the 
dust  in  the  air,  and  thus  acquire  tuberculosis  by  inhalation.  Again,  the 
child  may  infect  its  fingers  by  handling  various  articles,  and,  by  convey- 
ing the  infection  to  its  mouth,  tuberculosis  by  ingestion  may  result.  Lastly, 
should  the  child's  nails  be  neglected,  it  may  scratch  itself  with  the  infected 
fingers,  and  thus  tuberculosis  of  the  skin,  or  lupus,  may  result. 

If  the  following  precautions  are  observed,  these  infections  may  be  pre- 
vented. All  tuberculous  patients  should  be  careful  as  to  the  disposition  of 
their  expectoration,  and  should  associate  as  Uttle  as  possible  with  young 
children.  Children  should  never  be  kissed  on  the  mouth,  and  should  be 
taught  never  to  kiss  or  be  kissed  by  strangers.  The  fioor  on  which  the  child 
plays  should  be  kept  scrupulously  clean.  Carpets  sei^ve  only  as  dust  and 
dirt  collectors,  and  not  infrequently  harbor  the  germs  of  contagious  diseases; 
for  this  reason  they  should  never  be  used  on  the  floor  of  play-rooms.  The 
hands  and  nails  of  children  should  be  kept  as  clean  as  possible.  Expec- 
torating on  playgrounds  should  be  considered  a  grave  offense  and  be  pun- 
ished accordingly. 

At  school  the  child  may  contract  an  ingestion  tuberculosis  from  par- 
taking of  the  half-eaten  fruit  of  its  tuberculous  fellow-pupils,  or  by  the 
exchange  of  bean-blowers,  musical  mouth  instruments,  or  chewing-gum. 

Inoculation  of  the  child  Avith  tuberculosis,  even  if  it  is  not  predisposed 
to  the  disease,  is  occasionally  effected  through  ritual  circumcision.    This 


OVERCOMNG    PREDISPOSITION   AND   INFECTION. — KNOPF.  647 

form  of  infection  manifests  itself  first  as  a  local  disease  of  the  genital  organs, 
later  becoming,  in  a  great  number  of  cases,  generalized.  As  a  remedy  for 
this  evil  it  is  suggested  that  only  such  persons  be  allowed  to  perform  cir- 
cumcision as  have  proved  before  a  medical  board  of  examiners  that  they 
have  the  necessary  skill.  They  should  be  compelled  to  submit  themselves 
to  a  medical  examination  each  time  they  are  called  upon  to  perform  the 
rite.  Only  when  bearing  a  certificate  from  a  regular  physician  stating 
their  absolute  freedom  from  specific  diseases  should  they  be  allowed  to  per- 
form ritual  circumcision. 

Another  reliable  measure  against  the  possibility  of  inoculating  the 
child  when  the  parents  insist  upon  the  orthodox  method  of  circumcising,  is 
that  of  suction  by  the  aid  of  a  glass  tube,  as  practised  in  France  and 
Germany. 

Another  source  of  exposure  of  the  non-tuberculous  child  to  tuberculous 
infection  is  the  custom,  in  some  cities,  of  sending  foundlings  who  do  not 
improve  in  the  hospitals  to  homes  in  the  country.  These  children  are  often 
taken  into  families  in  which  an  invalid,  who  not  infrequently  is  tuberculous, 
is  intrusted  with  their  care. 

A  purely  philanthropic  scheme,  intended  to  overcome  the  predisposition 
a  child  may  have  inherited  from  its  tuberculous  parents,  was  inaugurated 
some  years  ago  by  Grancher,  of  Paris.  This  was  conducted  by  a  society 
called  "I'Oeuvre  de  preservation  de  I'enfance  contre  la  tuberculose,"  a 
society  to  protect  children  from  becoming  tuberculous.  This  society, 
through  its  agents,  selects  children  from  tuberculous  parents,  and  sends 
them  to  homes  in  the  country,  where  they  are  carefully  supervised  by  the 
society's  agents.  Proper  food,  outdoor  life,  and  hygienic  surroundings 
are  secured  for  the  children,  and  the  society's  reports  show  that  the  work 
has  resulted  in  the  preservation  of  life  and  the  gaining  of  health  and 
strength,  which  is,  after  all,  the  surest  immunity  against  tuberculosis. 

It  should  be  the  rule  in  private,  dispensary,  and  hospital  practice  to 
insist  upon  the  examination  of  all  children  of  tuberculous  parents.  All 
children  entering  public,  parochial,  or  private  schools  should  also  be  ex- 
amined periodically.  The  more  attention  we  pay  to  avoiding  tuberculous 
infection  during  childhood;  the  more  carefully  we  aim  to  effect  the  early 
recognition  of  a  condition  predisposing  the  child  to  tuberculosis;  the  more 
we  direct  our  energy,  skill,  and  knowledge  to  this  end,  and  the  more  we 
interest  philanthropic  persons  in  the  cause  of  overcoming  this  tuberculous 
predisposition,  the  gi-eater  are  our  chances  for  ultimately  eradicating  the 
disease  in  the  adult  and  becoming  complete  masters  of  the  great  white 
plague. 


SECTION  IV. 


Tuberculosis  in  Children — Etiology,  Prevention 
and  Treatment  [Continued), 


FIFTH  DAY.    MORNING  SESSION. 

Friday,  October  2,  1908. 

PROGNOSIS.     HYGIENE  OF  THE  MUCOUS   MEMBRANE.     SEA  AIR 
TREATMENT.     TREATMENT  OF  GLANDULAR  TUBERCULOSIS. 


The  President,  Dr.  Jacobi,  called  the  Section  to  order  at  ten  o'clock. 


OEUVRE  DE  LA  PRESERVATION  DE  L'ENFANCE 

CONTRE  LA  TUBERCULOSE— SECTION 

LYONNAISE. 

Par  Dr.  Edmond  Weill, 

Lyon. 


L'Oeuvre  Lyonnaise  de  la  preservation  de  I'enfance  contre  la  tuberculosa 
s'est  fondee  au  mois  d'Avril  1906.  Elle  est  rirougeusement  calquee  sur 
I'oeuvre  similaire  fondee  a  Paris  en  1904  par  le  regrett6  professeur  Grancher, 
qui  a  d'ailleurs  contribu^  largement  h  r^pandre  les  id^es  et  leurs  applications 
pratiques  dans  les  diff^rents  centres  provinciaux. 

Le  but  poursuivi  par  Grancher  et  par  ceux  qui  se  sont  associ^s  k  ses 
efforts,  a  ^te  de  soustraire  les  enfants  sains  au  contact  des  tuberculeux, 
dans  les  families  mis^rables  ou  peu  aisees. 

L'oeuvre  de  la  preservation  considere  comme  acquises  un  certain  nombre 
de  notions  relatives  au  d^veloppement  de  la  tuberculose. 

La  contagion  parait  jouer  le  role  principal  dans  la  propagation  de  cette 
maladie.  L'h^redite  n'agit  communement  que  comme  cause  predispo- 
sante,  exceptionellement  comme  cause  efficiente.  La  contagion  s'exerce 
d'autant  plus  activement  que  la  predisposition  hereditaire  est  mieux  etablie, 
que  le  contact  entre  les  sujets  infectes  et  les  sujets  sains  est  plus  etroit; 
par  consequent  elle  menace  surtout  les  families  pauvres  qui  vivent  dans 

648 


OEUVRE    DE   LA    PRESERVATION    DE  l'eNFANCE    DE   LYON. — WEILL.       649 

les  caux  etroits,  mal  acres,  souvent  mal  tenus,  et  encombres  par  un  nombre 
trop  considerable  d'habitants.  On  peut  aj outer  que  les  conditions  d'hygiene 
generals  relatives  a  Talimentation,  au  soleil,  a  I'air,  au  repos,  y  sont  deplor- 
ables  et  ajoutent  leur  effet  favorisant.  On  sait,  d'autre  qu'a  conditions  de 
milieu  ^gales,  les  enfants  sont  plus  particulierement  exposes  a  contracter  la 
tuberculose. 

Les  faits  observes  par  Epstein  a  Prague,  par  Heller  a  Nuremberg  et  k 
]\lunich,  demontrent  qu'en  eloignant  les  jeunes  enfants  des  families  tuber- 
culeuses,  on  les  preservait  completement.  A  I'orphelinat  agricole  de  St. 
Martin,  pres  de  Tours,  127  enfants  pris  dans  des  families  tuberculeuses,  et 
suivis  pendant  de  longues  annees,  n'ont  fourni  que  trois  cas  de  tuberculose. 
Leurs  freres  et  soeurs,  restes  dans  la  famille,  sont  tous  morts  tuberculeux. 
La  tentative  de  Grancher  est  conforme  a  toutes  les  donnees  cliniques  et 
experimentales,  qu'on  a  pu  r^unir  sur  la  tuberculose,  et  se  justifie  pleinement. 

Les  objections  qui  lui  ont  et^  faites  n'ont  pas  tenu  devant  I'experience. 
On  a  pretendu  que  les  parents,  meme  pauvres,  se  separaient  difficilement 
de  leurs  enfants.  C'est  une  erreur.  Du  moment  que  le  pere  ou  la  mere 
sont  tuberculeux,  la  misere  devient  intolerable  dans  le  menage,  et  les  parents 
confient  volontiers  leurs  enfants  a  des  societes  d' assistance,  souvent  dans  le 
seul  but  de  leur  procurer  quelque  bienetre,  a  plus  forte  raison  si  la  sante 
de  I'enfant  doit  y  trouver  son  avantage.  II  nous  est  arrive  de  recevoir  dans 
notre  oeuvre  3,  4  et  jusqu'a  5  enfants  de  la  meme  famille. 

On  a  pretendu  aussi  que  le  sujet  frappe  de  la  tuberculose  dans  une 
famille  quittait  les  siens  pour  etre  traite  dans  un  hopital  ou  dans  un  sana- 
torium. Or  il  est  beaucoup  de  tuberculeux  valides,  qui  frequentent  les 
dispensaires  antituberculeux  ou  qui  ne  se  traitent  meme  pas  du  tout,  et 
qui  continuent  a  travailler.  Sans  compter  les  phtisies  de  forme  fibreuse, 
on  peut  signaler  a  ce  point  de  vue,  les  sujets  atteints  d'osteite,  d'abces  froids, 
de  fistule  k  I'anus,  d'arthropathies,  qui  continuent  a  resider  au  milieu  des 
leurs  et  a  repandre  autour  d'eux  de  nombreux  germes  de  la  tuberculose. 

On  a  pretendu  aussi  que  le  placement  d'enfants  tires  d'un  milieu  tuber- 
culeux etait  difficile,  et  ne  pouvait  s'effectuer  que  dans  des  collectivites 
speciales,  telles  que  des  colonies  agricoles.  Ce  serait  1^,  en  effet,  une  tres- 
heureuse  solution  de  la  question,  et  il  serait  a  desirer  que  dans  chaque  rdgion 
se  creat  une  colonie  de  ce  genre,  pour  y  recevoir  les  enfants  menaces  par  la 
tuberculose.  II  suffit,  dans  une  grande  ville,  de  parcourrir  un  hopital 
d'adultes,  pour  voir  le  nombre  de  tuberculeux  gravement  atteints.  II 
suffit  de  feuilleter  les  r(5gistres  des  dispensaires  antitul^erculeux  pour  recon- 
naitre  I'^norme  proportion  des  tuberculeux  relativement  valides.  11  est 
presque  naif  de  dire  que  la  tuberculose  est  la  maladie  par  excellence  des 
classes  miserables,  et  le  nombre  d'dtablissements  agricoles  pour  rccueillir 
leurs  enfants  depasserait  de  beaucoup  les  ressources  dont  peuvent  disposer 
les  hygienistes  et  les  administrations  de  chaque  region. 


650  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

Aiissi  faut  il  accepter  sans  reserve,  pour  le  moment  du  moins,  la  com- 
bination tres  simple  et  tres  heureuse  imaginee  par  Grancher.  EUe  consiste 
a  placer  les  enfants  dans  des  families  de  paysans,  au  grand  air,  a  la  campagne, 
s'il  se  pent  sur  une  altitude.  L'enfant  est  en  pension,  I'oeuvre  paye  aux 
nourriciers  une  retribution  qui  varie  suivant  I'age.  A  Lyon,  nous  donnons 
15  fr.  par  mois  pour  les  enfants  au  dessus  de  dix  ans;  20  fr.  par  mois  pour 
ceux  qui  ont  de  six  a  dix  ans;  25  fr.  par  mois,  au  dessous  de  six  ans.  En 
comptant  le  trousseau,  les  frais  de  deplacement,  les  depenses  exceptionnelles, 
on  pent  estimer  le  prix  de  pension  entre  300  et  400  fr.  par  an. 

Lorsqu'on  place  plusieurs  freres  ou  soeurs,  on  tache  de  les  reunir  dans 
la  meme  famille,  ce  que  maintient  plus  facilement  encore  les  liens  de  la 
consanguineite  et  facilite  la  tache  du  nourricier. 

L'oeuvre  de  la  preservation  de  I'enfance  est  purement  hygienique. 
Elle  laisse  aux  parents  la  direction  complete  de  leurs  enfants.  C'est  aux 
parents  a  s'entendre  avec  les  nourriciers  sur  les  questions  d'instruction, 
d'education,  de  morale.  De  meme  les  parents  sont  lil^res  de  faire  visite  a 
leur  enfants  et  de  les  retirer,  a  n'importe  quel  moment,  de  la  famille  du 
nourricier. 

II  va  de  soi,  que  le  choix  du  nourricier  n'est  pas  laisse  au  hasard.  II 
doit  presenter  des  conditions  de  probite,  de  moralite  et  de  sante  qui^donnent 
toutes  garanties  a  la  famille  de  l'enfant. 

Les  enfants  sont  tous  repartis  dans  un  certain  nombre  de  foyers  qui  vont 
se  multipliant.  Nous  en  possedons  actuellement  21  dans  l'oeuvre  lyonnaise. 
Chaque  foyer  se  trouve  dans  la  circonscription  d'un  medecin  qui  fait  I'in- 
spection  gratuite  des  enfants  et  transmet  ses  observations  a  1' administration 
centrale. 

Au  debut,  les  paysans  qui  acceptaient  des  enfants  en  pension,  etaient  un 
peu  emus  par  le  mot  tuberculose  qui  figure  dans  I'intitule  de  l'oeuvre.  lis 
ont  compris  rapidement  qu'on  ne  leur  envoyait  que  des  enfants  sains,  et 
sont  tres  heureux  de  cette  nouvelle  aubaine  qu'ils  doivent  a  I'hygiene,  et 
qui  constitue  pour  eux  un  appoint  qu'ils  sont  loin  de  dedaigner.  L'oeuvre 
de  la  preservation  de  I'enfance  contre  la  tuberculose,  telle  que  je  viens  d'en 
exposer  les  grandes  lignes,  a  subi  I'epreuve  du  temps.  A  Paris,  oi^i  elle 
fonctionne  depuis  4  ans,  elle  est  en  pleine  prosperite.  Le  nombre  des 
pupilles  depasse  300.  A  Lyon  en  2  ans,  nous  avons  place  100  enfants,  et  a 
I'heure  actuelle  nous  payons  pension  pour  plus  de  50,  ce  qui  constitue  une 
depense  annuelle  variant  entre  15,000  et  20,000  fr.  L'oeuvre  de  la  preser- 
vation du  type  Grancher  a  evite  avec  soin  les  grosses  depenses  d'installation, 
d'arrangement  et  d' administration  qu'entrainerait  la  creation  d'etablisse- 
ments  coUectifs. 

Elle  a  encore  I'avantage  de  maintenir  pour  les  enfants  la  vie  familiale, 
car  entre  pupilles  et  nourriciers,  I'enteret  se  double  bientot  de  sentiments 
plus  affectifs,  tels  qu'en  inspire  fatalement  la  vie  en  commun  avec  des  en- 


OEUVRE    DE   LA    PRESERVATION    DE    l'eNFANCE    DE    LYOX. — WEILL.     651 

fants.  Ceux-ci  s'attachent  egalement  a  leur  nouvelle  famille,  a  la  vie  de 
campagne  si  goutee  par  de  malheureux  enfants  habitues  aux  sombres  taudis 
de  la  grande  ville.  II  est  nous  arrive  de  voir  des  pupilles  refuser  de  quitter 
leurs  nourriciers  pour  revenir  chez  leurs  parents.  Un  de  nos  nourriciers  a 
demande  a  garder  a  sa  charge  complete,  un  pupille  devenu  orphelin. 

Si  bien  calculee  que  soit  I'oeuvre  pour  restreindre  la  depense,  elle  est 
encore  tres  onereuse.  II  ne  s'agit  pas  en  effet,  de  placer  les  enfants  a  la 
campagne  pour  quelques  semaines,  comme  I'exemple  en  est  donne  par  les 
colonies  de  vacances,  c'est  par  mois  et  par  annees,  qu'il  faut  compter  et 
comme  chaque  pupille  revient  a  300  fr.  environ,  sans  compter  les  frais 
accessoires  et  les  imprevus,  on  peut  pressentir  que  les  demandes  ne  peuvent 
pas  etre  toutes  acceuillies.  Nous  faisons  un  choix  parmi  les  enfants  qui 
sollicitent  notre  assistance.  Ce  sont  les  families  les  plus  interessantes  que 
nous  favorisons  de  preference.  A  ce  point  de  vue,  nous  avons  recours  aux 
renseignements  tres  precis  fournis  par  le  dispensaire  antituberculeux  de 
Lyon,  cree  et  dirige  par  notre  ami,  le  professeur  Jules  Courmont.  Le 
dispensaire  antituberculeux  possede  des  enqueteurs  qui  vont  dans  les 
families  de  tuberculeux,  se  documentent  tres  exactement  sur  leur  situation, 
et  nous  signalent  les  cas  les  plus  urgents  et  les  plus  dignes  d'interet.  Aussi 
les  deux  oeuvres  se  completent  elles  tres  heureusement. 

Ce  qui  restreint  dans  une  certaine  mesure  les  dej^enses  de  I'oeuvre,  c'est 
le  renvoi  de  I'enfant  motive  soit  par  la  demande  des  parents,  soit  par  la 
gue risen  du  tuberculeux  qu'on  fuyait,  soit  ce  qui  arrive  plus  souvent  par 
sa  mort.  Au  1  Avril  1908,  nous  avons  place  92  enfants  en  I'espace  de  pres 
de  2  ans.  Sur  ces  92,  46  soit  50%,  ont  abandonne  les  avantages  de  I'oeuvre; 
1  enfant  est  decede;  1  enfant,  orphelin,  a  ete  adopte  definitivement  par  ses 
nourriciers;  4  ont  ete  places  a  I'assistance  publique;  12  ont  ete  rappeles 
par  leur  famille;  28  ont  ete  renvoyes  apres  deces  des  parents  malades. 

En  somme,  sur  92  places  en  un  peu  moins  de  2  ans,  il  ne  restait  a  la  charge 
de  I'oeuvre  que  46  enfants  au  1  Avril  1906,  II  est  vrai  que  depuis  le  1  Avril 
nous  avons  accorde  la  pension  a  10  enfants,  ce  qui  nous  fait  actuellement 
56  enfants  a  notre  charge.  Une  des  lacunes  penibles  de  nos  reglements  est 
relative  au  renvoi  d 'enfants  dont  un  des  parents,  atteint  de  tuberculose,  est 
mort.  Get  evenement  s'il  fait  disparaitre  la  cause  meme  qui  avait  fait 
accorder  la  pension  de  I'oeuvre  aux  enfants,  ne  laisse  pas  que  d'augmenter 
ou  d'entretenir  la  misere  du  menage. 

L'experience  relativement  courte  que  nous  ont  donnee  deux  ans  de 
pratique  de  I'oeuvre  de  la  preservation  de  I'enfance  contre  la  tuberculose, 
nous  permet  cependant  de  parter  sur  son  role  un  jugement  favorable. 
Actuellement  nous  avons  plac6  plus  de  100  enfants  sur  lesquels  nous  n'en 
avons  perdu  qu'un  seul,  par  maladie  accidentelle  (une  fievre  Eruptive). 
Aucun  n'est  devenu  tuberculeux,  bien  que  pour  un  tiers  des  cas  I'observation 
se  soit  prolong6e  pr^s  de  deux  ans. 


THE  PROGNOSIS  IN  PULMONARY  TUBERCULOSIS  IN 
CHILDREN  UNDER  FIFTEEN  YEARS  OF  AGE. 

By  Frank  A.  Craig,  M.D., 

Philadelphia. 


The  ability  to  form  a  correct  prognosis  in  any  disease  must  depend  largely 
upon  the  knowledge  obtained  by  personal  experience.  Considerable  assis- 
tance, however,  may  be  gained  from  a  study  of  the  experiences  of  others, 
especially  with  regard  to  the  results  obtained  under  certain  definite  conditions. 
The  object  of  this  article  is  to  compare  the  results  obtained  in  children 
with  those  secured  in  adults,  and,  analyzing  the  conditions  present  at  the 
first  examination,  to  determine  whether  there  were  any  factors  that  might 
be  considered  as  having  special  prognostic  significance. 

The  deductions  here  made  are  the  result  of  a  study  of  193  cases  of  pul- 
monary tuberculosis  treated  during  the  past  five  to  eight  years  in  the  White 
Haven  Sanatorium  and  in  the  Henry  Phipps  Institute,  both  in  the  dispensary 
and  in  wards  of  the  latter. 

No  cases  were  considered  that  had  not  been  in  the  sanatorium  for  at 
least  thirty  days,  and  that  were  under  observation  in  the  dispensary  for 
less  than  seventy-seven  days,  with  four  visits  as  a  minimum.  Unless  other- 
wise stated,  the  cases  with  disease  arrested,  much  improved,  and  improved 
will  be  grouped  together  under  the  heading  "improved,"  and  the  stationary, 
progressive,  and  fatal  cases  under  the  heading  "  unimproved." 

The  findings  have  been  arranged,  first,  by  making  a  comparison  of  the 
results  obtained  according  to  age,  sex,  involvement,  etc.;  the  subject  is 
then  considered  as  a  whole,  with  special  reference  to  any  special  factors 
that  may  seem  to  have  a  bearing  on  the  question. 

Sex. 
TABLE  I.— RELATION  BETWEEN  THE  RESULT  OF  TREATMENT  AND  SEX. 

Males.  Females. 


Disea.se  arrested...  35— 36.5%  \     .„     aq  no/  ]  32— 33%  \    .^.^^ 

Much  improved....  12— 12.5%/    «'— 4^-^/0  87.5%               7—7%/   *"/<= 

Improved 37—38.5%,       37—38.5%,!  -36-37%       37% 

Stationary 7—  7.5%  "I  10—11%]             ^ 

Progressive 2—  2.0%  \    12—12.5%  \  12.5%               7—  7%  \   23%, 

Died 3—3.0%]                        J  5—5% 

Total  cases, 96 97 

652 


77% 
23% 


PROGNOSIS   IN   CHILDREN   UNDER   FIFTEEN. — CRAIG. 


653 


In  the  present  series  of  cases  the  males  showed  slightly  better  results, 
the  percentages  being  higher  in  all  the  groups  in  which  the  result  was  favor- 
able, and  lower  in  those  in  which  it  was  unfavorable.  The  difference, 
however,  is  so  sHght  as  to  warrant  no  further  conclusion  beyond  the  state- 
ment that  boys  apparently  respond  somewhat  better  to  treatment  than 
girls.  The  sexes  were  almost  equal  in  number,  and  neither  showed  any 
special  liability  to  the  disease. 

Age. 
TABLE  II.— RELATION  BETWEEN  RESULT  AND  AGE. 


Years. 

14 

35% 

14% 

32% 

5% 

5% 

9% 

13 

12 

11 

10 

9 

43% 

0% 

43% 

14% 

0% 

0% 

8 

37% 

0% 

26% 

37% 

0% 

0% 

8 

7 

20% 
10% 
40% 
20% 
0% 
10% 

10 

6 

18% 
9% 

73% 
0% 
0% 
0% 

11 

5 

25% 

0% 

50% 

25% 

0% 

0% 

4 

50% 
50% 
0% 
0% 
0% 
0% 

3 

1-3 

Arrested  

Much  improved 

42% 
16% 
23% 

3% 
10% 

6% 

39% 
14% 
36% 

0% 
11% 

0% 

31% 

6% 
37% 
19% 

0% 

7% 

33% 
0% 

57% 
5% 
5% 
0% 

25% 

0% 

50% 

25% 

0% 

0% 

0% 
0% 
0% 

Stationary 

Progressive 

Died 

100% 
0% 
0% 

Number  of  cases  ... 

43 

31 

28 

16 

21 

14 

4 

2 

4 

1 

TABLE  III.— RELATION  BETWEEN  RESULT  AND  AGE  (Condensed). 


Years. 


Arrested  and  much  improved . .  . 

Improved 

Stationary,  progressive,  and  died 

Number  of  cases 


10-14 
Inclusive. 


6-9 

Inclusive. 


48.2%  \  oqro7i35%\  0107 
3.5.3%/  ^'^•^/M6%/  ^^/'' 
16.5%  [■    16.5%  19%,  \    19% 


139  (72%) 


47  (24.4%) 


AND   UnDEE. 


36%  \     790/ 

36%/    ^-/« 
28%  \    28% 


7  (3.6%) 


The  ages  range  from  sixteen  months  to  fourteen  years,  the  majority  of 
the  cases  being  between  ten  and  fourteen  years,  only  10  being  under  six 
years  of  age.  For  this  rea.son  the  figures  for  the  younger  children  have  very 
little  significance.  The  older  cases  show  a  better  result  than  the  younger. 
Those  between  ten  and  fourteen  years  show  only  very  slightly  better  re- 
sults than  those  between  six  and  nine  years;  the  results  in  those  of  five 
years  and  under  are  not  nearly  so  good  as  in  the  older  cases,  but,  as  has  been 
stated,  there  were  so  few  of  the  cases  in  this  last  age  period  that  the  value 
of  the  statement  in  regard  to  these  very  young  cases  is  much  reduced. 

A  great  deal  has  been  written  regarding  the  unfavorable  prognosis  in 
young  children,  especially  in  those  under  eight  years  of  age,  and  yet,  from  a 
glance  at  Table  II,  it  will  l^e  seen  that  only  one  case  was  progressive  or  fatal 
in  children  under  eight  years  of  age,  all  the  remaining  cases  that  failed  to 
improve  being  stationary.     Bonney  goes  so  far  as  to  state  that  "No  child 


654 


SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 


under  eight  years  has  secured  an  arrest  of  pulmonary  tuberculosis  wliile 
under  my  supervision."  He  mentions  the  extremely  satisfactory  results 
in  children  between  eight  and  fifteen  years.  From  the  present  figures  it 
would  appear  that  the  results  are  better  in  children  over  five  years,  and  the 
prognosis  is  slightly  better  in  those  above  than  in  those  under  nine  years. 

Race. 
TABLE  IV.— RELATION  BETWEEN  RESULT  AND  RACE. 


Celt. 

Hebrew. 

Teuton. 

American. 

Arrested 

3       15%  \     pEcy 

2—10%/    ^^/-^ 
9—45%       45% 
1-  5%  ] 
3—15%       30% 
2-10%  J 

5— 22.5%  \    27C7 
1—  4.5%  /    ^^  /<= 
12—55.0%       55% 
3—13.5%  ] 

0—  0.0%       18% 

1-  4.5%  J 

0 
0 

11—100% 
0 
0 
0 

Much  improved 

Improved 

Stationary 

Q           ^0  j    25% 

1—25%  25% 
0              ] 

Progressive 

Died 

1—25%  50% 
1-25%  J 

Number  of  cases 

20  (28%) 

22  (31%) 

11  (15%) 

4  (5%) 

Table  IV  (Continued). — Relation  Between  Result  and' Race. 

Negro. 

Latin. 

Anglo- 
Saxon. 

White. 

Black. 

Arrested  . 

4—36.0%  1 

0 

0 

63—35.0%  1 

4—36.0%  ] 

Much  Im- 

36% 

45% 

36% 

proved  . 

0 

0 

0 

19—10.0%  J 

0                 J 

Improved 

4—36.0% 

36% 

Station- 

1—50% 

2—100% 

69—38.0%       38% 

4—36.0% 

36% 

ary   .... 

1—  9.3% 

1—50% 

0 

16—  9.0% 

1—  9.3%  ■ 

Progres- 

28% 

sive  .... 

1—  9.3% 

0 

0 

8-  4.5%       17% 

1—  9.3% 

28% 

Died  .... 

1—  9.3%  J 

0 

0 

7-  3.5%  J 

1—  9.3%  J 

Number 

of  cases 

11  (15%) 

2  (3%) 

2  (3%) 

182 

11 

In  the  cases  studied  the  race  was  recorded  in  only  a  small  proportion  of 
the  histories  (68).  It  was  a  rather  curious  coincidence  (?)  that  the  eleven 
Teutons  or  children  of  Teutonic  parents  were  all  improved — in  other  words, 
none  of  them  did  very  well  or  very  ill.  The  Celts  showed  improvement  in 
70  per  cent,  of  the  cases  and  the  Hebrews  in  82  per  cent.  The  other  races 
were  represented  by  so  few  that  the  figures  are  useless. 

Color. 
Although  there  were  only  eleven  negroes  studied,  the  high  proportion 
showing  improvement  is  rather  remarkable.     (See  Table  IV.) 


PROGNOSIS   IN   CHILDREN    UNDER   FIFTEEN. — CRAIG. 


655 


The  relative  percentage  of  those  showing  improvement,  while  not  so  good, 
compares  very  favorably  with  the  results  in  the  whites,  notwithstanding  the 
general  view  to  the  contrary.  The  only  reason  to  account  for  tliis  rather 
unexpected  finding  is  the  fact  that  a  gi-eater  proportion  of  them  were  treated 
in  the  sanatorium,  where  the  results  were  better  than  in  the  dispensary. 
(See  Method  of  Treatment,  further  on.) 

Duration  of  Disease. 
TABLE  v.— RELATION  OF  RESULT  AND  DURATION  OF  DISEASE. 


Arrested  and  much  improved . . . 

Improved 

Stationary,  progressive  and  died 

Total 

Unrecorded,  8. 


Three 
Months 

AND  Less. 


27— 49.0%c) 

19—34.6% 

9—16.4%, 


55  (30%) 


Three  to 
Six  Months. 


15—35.7% 
15—35.7% 
12—28.6% 


42  (23%) 


Six 
Months  to 
One  Year. 


15—37.5% 

18—45.0% 

7—17.5% 


40  (21%) 


Table  V  (Continued). — Relation  of  Result  and 

Duration 

OF  Disease. 

One  to  Two 
Years.  ^ 

Two  to 
Four 

Years. 

Four  to 
Eight 
Years. 

Over 
Eight 
Years. 

Arrested  and  much  improved 

5— 38.5%c) 
7—53.9% 
1—  7.6% 

12—54.6% 
7—31.8% 
3— 13.6%o 

4—40% 
5—50% 
1—10% 

1—33% 

Improved 

1—33% 

Stationary,  progressive  and  died 

1— 33%o 

Total 

13  (7%) 

22  (12%) 

10  (5%) 

3  (2%) 

There  is,  perhaps,  no  datum  obtainable  in  the  histories  of  tuberculous 
patients  that  is  so  indefinite  and  uncertain  as  the  duration  of  disease.  The 
phrase  "period  of  manifestation"  would  be  a  more  appropriate  title  for  tliis 
division  of  the  subject,  as  that  is  really  what  the  figures  indicate.  To 
determine  this  point  with  any  degree  of  accuracy,  requires,  in  the  average 
case,  considerable  care  on  the  part  of  the  examining  physician. 

The  cases  have  been  divided  into  groups  as  follows:  Three  months  and 
under,  six  months,  one,  two,  three,  four,  and  eight  years  and  over.  In 
these  groups  the  cases  that  were  unimproved  followed  a  rather  peculiar 
curve. 

Starting  with  those  of  shortest  duration,  with  16.4  per  cent,  of  unim- 
proved cases,  there  is  a  slight  rise  in  the  next  division;  the  proportion  then 
falls  in  the  one  year  division,  and  again  in  the  one  to  two  year  division,  where 
it  is  the  lowest  of  all  (7.6  per  cent.).    The  curve  then  gradually  rises  in  the 


656 


SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 


four  and  eight  year  division,  with  a  marked  rise  in  the  cases  of  longer  than 
eight  years'  duration,  wliere  it  is  the  highest  of  all  (33  per  cent.). 

The  explanation  suggested  is  that  the  cases  with  a  history  of  only  a 
few  months'  duration  are  probably  more  acute  in  type  than  those  that  have 
lasted  longer.  These  more  chronic  forms  respond  well  to  treatment,  pro- 
vided they  receive  the  proper  attention  before  the  condition  has  existed  too 
long.  The  rather  high  proportion  of  unimproved  cases  in  those  of  six 
months'  duration  is  probably  due  to  the  fact  that  in  the  more  acute  cases 
the  disease  has  had  an  opportunity  to  extend  further. 

The  majority  of  cases  were  of  one  year's  duration  or  less,  and  yet  the 
number  of  cases  in  wMch  the  disease  had  existed  much  longer  is  surprisingly 
high.  ]\Iost  writers  state  that  the  disease  is  of  cjuite  short  duration  in  chil- 
dren. Ashby  and  Wright  state  that  "the  progress  of  such  cases  is  apt  to 
be  more  rapid  than  it  is  in  adults,  a  fatal  result  occurring  in  four  to  six 
months."  In  the  present  series  of  cases,  at  least,  there  was  nothing  to 
indicate  that  any  such  rapid  progress  occurred. 

In  the  belief  that  tliis  might  be  explained  by  a  study  of  the  relation  be- 
tween the  duration  of  the  disease  and  the  amount  of  lung  tissue  involved 
the  following  table  was  prepared. 


TABLE  VI. 


-RELATION   OF   DURATION   OF   DISEASE   AND   AMOUNT  OF 
INVOLVEMENT. 


One  apex  and  one  lobe 

Both   apices,   one   apex   and  one 

lobe,  and  two  lobes 

One  to  two  lobes,  with  cavity 

More  than  two  lobes 


Three  Months 

AND  Less. 


33—63%  ] 

88% 
13—25%  j 

6—12%  /  ^^^^ 


Three  to  Six 
Months. 


24—57% 


13—31% 
4—10%  /   ^^/^ 


Six  Monthb  to 
One  Year. 


90% 


80% 
10%  . 
:=  1  }  10% 


Table  VI  (Conlinucd) 

— Relation  of  D 

URATION 

OF  Disease  and  Amount  of 

Involvement. 

One  to  Two 

Four  to  Eight 

Over  Eight 

Years. 

Two  to  Four    Years. 

Years. 

Years. 

One  apex  and 

1 

1 

one  lobe .... 

7- 

-53% 

16—73  % 

6—60% 

2—66% 

Both       apices, 

one      apex 

[  84% 

f  95.5% 

80% 

100% 

and       one 

lobe,        and 

two  lobes . .  . 

4- 

-31% 

5—22.5% 

2—20% 

1—33%  . 

One     to      two 

lobes,      with 

cavity 

0 

16% 

1-     4.5% 

4.5% 

1—10% 

■  20% 

0 

More  than  two 

lobes 

2- 

-16%  J 

0                    J 

1-10%  J 

0 

PROGNOSIS   IN   CHILDREN    UNDER   FIFTEEN. — CRAIG. 


657 


A  study  of  this  table  shows  that  there  is  absolutely  no  definite  relation 
between  the  amount  of  involvement  and  the  duration  of  the  disease.  It 
does,  however,  confirm  to  a  certain  extent  the  statements  made  in  regard  to 
the  cases  of  shorter  duration  being  probably  of  a  more  acute  form;  at  least 
we  do  not  find  so  high  a  percentage  of  very  slight  involvement  in  the  six  as 
in  the  three  month  cases.  At  one  year,  however,  we  find  the  highest  per- 
centage of  very  slightly  involved  cases.  This  can  be  explained  only  on  the 
grounds  that  these  cases  are  of  the  more  chronic  type  of  disease.' 


Amount  of  Pulmonary  Involvement. 

TABLE  VII.— RELATION  OF  RESULT  AND  AMOUNT  OF  PULMONARY  IN- 
VOLVEMENT. 


One  Apex. 

One  Lobe. 

Two  Apices. 

One  Apex, 
One  Lobe. 

Arrested 

Much  improved . 
Improved 

31—40%  ] 

8—10%       90% 
31-40%  J 

8—10%  ] 

10% 

0               J 

16—31%  ]   94% 

8—16% 
24—47%  J 

3—  6%  ] 

6% 

0               J 

8—50%  ] 

1-  7%       93% 

6—36%  J 

0           1 

[     7% 

1-  7%  j 

7—37%  ] 
1—  5%      68% 
5—26%  J 
3—16%  ' 

32% 
3—16%  J 

Stationary 

Progressive  and 
died 

Total 

78  (40%) 

51  (26%) 

16  (8%) 

19  (10%) 

Table    VII    {Continued) . 


-Relation   of   Result    and   Amount  of   Pulmonary 
Involvement. 


Two  Lobes. 

One  or  Two 

Lobes  with 

Cavity. 

More  than  Two 
Lobes. 

More  Than  Two 

Lobes  with 

Cavity. 

Arrested 

Much  improved . . . 

Improved 

Stationary 

Progressive        and 
died 

.5—50%  1 
1—10%       80% 
2—20%  ] 
0 

20% 
2—20%  J 

^                  ] 
0 

2—40% 

1—20% 

2-40%  . 

•  40% 
^  60% 

0             1 

0                     43% 
3—43%  J 
1-14%  1 

57% 
3^3%  J 

0 

I 

1-14%  1 

100% 
6—86%  J 

Total 

10   (  5%) 

5   (  3%) 

7   (  4%) 

7   (  4%) 

The  amount  of  involvement,  as  would  naturally  be  expected,  gives  the 
most  definite  information  upon  which  to  base  a  prognosis.  The  figures  show 
some  very  interesting  facts.  So  far  as  improvement  was  concerned,  there 
was  practically  no  difference  between  the  cases  with  only  one  apex,  one  lobe, 
and  both  apices,  all  showing  but  a  small  proportion  of  cases  that  failed  to  im- 
prove. No  case  with  only  one  apex  involved  became  "progressively  worse" 
or  died.  The  proportion  of  improved  cases  decreases  in  the  cases  with  one 
lobe  and  one  apex,  and  also  in  those  with  two  lobes,  although  the  decrease 


658 


SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 


is  not  SO  great  in  the  latter.  When  we  consider  the  cases  with  one  or  two 
lobes  with  cavity  formation,  or  with  more  than  two  lobes  with  or  without 
cavity  formation,  we  find  that  in  no  single  case  is  the  "disease  arrested" 
or  "much  improved."  Moreover,  in  no  case  in  which  there  were  more  than 
two  lobes  involved,  with  cavity  formation,  was  there  any  improvement  in 
the  patient's  condition.  In  only  one  of  these  cases  did  the  disease  remain 
stationary.  These  findings  are  quite  in  accord  with  the  statements  of  var- 
ious writers  that  if  the  disease  is  advanced,  the  prognosis  is  very  unfavorable 
in  children. 

Stage  of  Disease. 
TABLE  VIII.— RELATION  OF  RESULT  AND  STAGE  OF  DISEASE. 


Arrested 

Much  improved 

Improved 

Stationary 

Progressive  and  died 

Total 


Incipient  (Favor- 
able). 


31—40%  ] 

7—  9%       89% 
31—40% 

8-11% 


0 


11% 


77    (40%) 


Moderately  Ad- 
vanced. 


36—38%  ] 

11—12%       88% 

36—38% 
6-   6%  \  j2(7 
6—  6%  /  ^^/^ 


95   (49%) 


Fab  Advanced. 


^  1 

1-  4%       33% 

6—29%  j 

3  14%      \     f,yo/ 

11—53%  /  ^''/o 


21    (11%) 


The  cases  have  been  divided  according  to  the  Turban  method,  as  modi- 
fied by  the  National  Association,  into  Stages  I,  II,  and  III. 

The  only  points  of  interest  in  this  regard  are  that  there  is  very  little 
difference  in  the  results  in  Stages  I  and  II,  except  that  in  Stage  I  there  were 
no  cases  that  became  progressively  worse  or  died.  In  Stage  III  only  one 
case  showed  much  improvement,  and  this  case  was  only  placed  in  Stage  III 
on  account  of  a  complication  (empyema),  the  patient  otherwise  being  in 
fairly  good  condition.  None  of  the  cases  in  this  stage  had  disease  arrested, 
and  the  majority  of  them  (67  per  cent.)  became  "progressively  worse"  or 
died. 

Source  of  Infection. 

TABLE  IX.— RELATION  OF  RESULT  AND  SOURCE  OF  INFECTION. 


Arrested 

Much  improved 

Improved 

Stationary 

Progressive  and  died 

Total 

Unrecorded  in  two  cases 


Parental. 


82% 


40—39% 

5-  5% 
38—38% 

8—  8% 
10—10%  /  18% 


101    (53%) 


Other  Sources. 


25—28%, 

14—15% 

35—39%, 

9—10% 

7-8% 


82% 


18% 


90   (47%) 


PROGNOSIS   IN   CHILDREN   UNDER   FIFTEEN. — CRAIG. 


659 


The  subject  under  discussion  may  seem  out  of  place  in  an  article  on 
prognosis.  The  view,  however,  that  children  whose  parents  are  or  have 
been  tuberculous  do  not  do  so  well  as  children  of  healthy  parents  is  so 
prevalent  that  it  was  deemed  advisable  to  consider  what  effect,  if  any,  a 
history  of  tuberculous  parentage  had  upon  the  result  of  treatment.  One 
frequently  encounters  such  statements  as  these:  "Family  history  of  con- 
sumption adds  to  the  gravity  of  the  outlook,  showing  a  lessened  power 
of  resistance  to  the  toxins"  (Taylor  and  Wells);  "The  personal  equation 
depends  largely  on  the  family  history;  if  good,  the  prognosis  is  hope- 
ful" (Cotton). 

When  one  compares  the  two,  one  finds  that  the  proportion  of  cases  that 
improved  and  of  those  that  did  not  improve  are  exactly  the  same  in  the  two 
groups.  One  finds,  moreover,  that  among  the  cases  in  which  there  was  a 
family  history  of  tuberculosis  in  one  or  both  parents  the  percentage  of 
cases  with  disease  arrested  was  higher  than  in  cases  in  which  there  was  no 
history  of  tuberculosis  in  the  parents.  The  latter,  however,  showed  a  lower 
percentage  of  progressive  and  fatal  cases.  We  are,  therefore,  led  to  con- 
clude that  a  history  of  tuberculosis  in  one  or  even  in  both  parents  does  not 
influence  the  prognosis  either  one  way  or  the  other.  It  is  barely  possible 
that,  in  those  cases  in  which  the  parents  are  known  to  be  suffering  from 
the  disease,  the  condition  may  be  recognized  earlier  and  the  case,  therefore, 
have  a  better  chance  of  recovery. 


Pulse-rate. 
TABLE  X.— RELATION  OF  RESULT  AND  PULSE-RATE. 


Arrested 

Much  improved 

Improved 

Stationary 

Progressive  and  died 

Total 


Sanatorium  and  Hospital  Cases. 


Eighty  and  Under. 


14—70%  1 
2—10% 
3—15% 
1-  5%  \ 
0  / 


Eighty-one  to  One 
Hundred. 


23—51% 
95%  11—25% 
7-15% 
0 


5% 


20    (23%) 


9%  / 


91% 
9% 


45   (52%) 


One  Hundred  and 

One  to  One  Hundred 

and  Twenty. 


5—28%  1 

1—  5%       55% 

4—22%  J 

2-11%  1  ..or 
6—34%  /  *^/o 


18   (21%) 


Over  One 
Hundred 

and 
Twenty. 


0 

0 

1—33% 

0 

2-67% 


3    (4%) 


660 


SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 


Table  X   (Continued). — Relation  of  Result  and  Pulse-rate. 


Arrested 

Much  improved  . 

Improved 

Stationary 

Progressive     and 
Died 

Total 


Dispensary  Cases. 


Eighty  and  Under. 


3—14% 
0 

18—82% 

1-  4% 

0 


4% 


Eighty-one  to  One 
Hundred. 


12—23% 
4-  8% 

28—54% 
8—15% 

0 


85% 


15% 


One  Hundred  and 

One  to  One  Hundred 

and  Twenty. 


7—32% 
1-  4% 
9—41% 
4—19% 

1-4% 


77% 


23% 


Over  One  Hundred 
and  Twenty. 


1-12% 
0 

2—25%    I 
1—12%  ^ 


4—51%  j 


37% 
63% 


22    (21%) 


52   (50%) 


22    (21%) 


8     (8%) 


The  figures  that  have  been  selected  for  the  estimation  of  the  value  of 
the  pulse-rate  have  been  taken  from  the  records  on  admission  or  at  the  first 
visit  of  the  patient.  Although  these  figures  are  open  to  many  objections  on 
the  grounds  of  being  uncertain  and  inaccurate,  still  they  represent  the  con- 
ditions under  which  the  pulse  is  usually  taken  when  one  is  called  upon  to 
give  a  prognosis.  The  figures  have  been  analyzed  with  the  object  of  deter- 
mining whether  the  pulse,  taken  under  these  various  conditions,  gives  any 
information  of  value  in  prognosis. 

As  some  of  the  records  were  made  in  the  dispensary,  they  have  been 
tabulated  separately,  since  the  conditions  were  so  very  different  from  those 
in  the  sanatorium  and  hospital  cases,  where  the  pulse  was  taken  with  the 
patient  at  rest.  As  one  would  expect,  the  pulse-rate  in  the  dispensary  cases 
ranged  slightly  higher  than  the  others,  although  not  to  a  very  marked  degree. 

It  will  be  seen  that  no  case  with  a  pulse  of  eighty  or  under,  in  either 
group  of  cases,  became  progressively  worse  or  died,  and  that  in  only  2  out 
of  the  42  cases  the  disease  remained  stationary.  The  proportion  of  cases 
that  failed  to  improve  increases  with  the  increased  pulse-rate. 

The  findings  in  the  sanatorium  and  hospital  cases  were  much  more 
constant  and  definite  than  in  the  dispensary  cases.  It  would  appear, 
therefore,  that  if  one  is  to  secure  the  most  accurate  information  from  the 
pulse  for  the  purpose  of  prognosis,  the  pulse  must  be  taken  with  the  patient 
at  rest.  This  applies  in  the  case  of  children  to  a  greater  extent  than  in 
adults,  as  the  pulse  in  children  is  more  readily  affected  by  excitement,  etc. 
When,  under  these  circumstances,  the  pulse  is  above  120  a  minute,  one 
cannot  expect  an  "arrest  of  disease"  or  even  "much  improvement";  with 
a  pulse  of  100  or  under  "arrest  of  disease"  or  "much  improvement"  may 
be  expected  in  80  per  cent,  of  the  cases,  two-thirds  of  these  cases  being  the 
former  (disease  arrested). 

Although  considerable  stress  has  always  been  laid  upon  the  importance 


PROGNOSIS   IN   CHILDREN   UNDER   FIFTEEN. — CRAIG. 


661 


of  the  pulse  as  an  aid  in  prognosis,  I  have  never  seen  any  figures  except  the 
present  that  so  clearly  demonstrate  this  fact. 


Respiratory  Rate. 
TABLE  XI.— RELATION  OF  RESULT  AND  RESPIRATORY  RATE. 


Sanatorium  and  Hospital,  Cases. 


Twenty-four  and 
Under. 


Twenty-five  to        Qver  Thirty-two. 
Thirty-two. 


Arrested 

Much  improved 

Improved 

Stationary 

Progressive  and  died 

Total 

Unrecorded,  12.     *  Empyemic 


24—56%  1 
11—21%    j^  98% 
11-21%  J 

0 

1- 


l 


2%   / 


2% 


0 


5—32%  1 

1—  5%  [  53% 
3-18% 

2-11%  \  47^ 

6—36%  /  ^'  /o  3—60% 


1—20%*       40% 
1-20%     J 

°  }  60% 


52    (70%) 


17    (23%) 


5   (7%) 


Table  XI  (Continued). — Relation  op  Result  and  Respiratory  Rate. 


Arrested 

Much  improved 

Improved 

Stationary 

Progressive  and  died 

Total 

Unrecorded,  12. 


Dispensary  Cases. 


Twenty-four  and 
Under. 


18—27% 

1—  2%    \  88% 
39—59% 

6—  9%  \ 

2—  3%  /  12% 


Twenty-five  to 
Thirty-two. 


67% 


0 

4—22% 
8—45% 
4-22%  \ 
2—11%  /  33% 


Over  Thirty-two. 


3—27% 

0  1-  82% 

6—55% 

2-18%  \ 

0  /  18% 


66   (69%) 


18   (19%) 


11    (12%) 


The  statements  in  regard  to  the  necessity  of  having  the  patient  at  rest 
apply  to  even  a  greater  extent  in  estimating  the  respiratory  rate  than  in  the 
case  of  the  pulse. 

Examining  the  findings,  therefore,  in  the  cases  in  which  the  records  were 
taken  in  the  sanatorium  or  in  the  hospital  wards  we  note,  then,  with  a 
respiratory  rate  of  24  or  less  only  one  ca.se  out  of  a  total  of  52  failed  to  im- 
prove. With  a  respiratory  rate  of  over  32  only  one  case  in  a  total  of  five 
showed  much  improvement,  this  case  being  complicated  by  an  empyema. 
None  of  the  cases  with  a  rate  over  32  had  disease  arrested. 

We  could,  therefore,  consider  a  respiratory  rate  of  24  or  less  a  very 
favorable  prognostic  sign,  and  one  over  32  very  unfavorable.  These  figures 
apply  only  when  obtained  with  the  patient  at  rest. 


662 


SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 


Temperature. 
TABLE  XII.— RELATION  OF  RESULT  AND  TEMPERATURE. 


Sanatorium  and  Hospital  Cases. 

98.8°  and  Under. 

99°  to  99.8° 

100=  to  100.8° 

101°  and  Over. 

Arrested 

25—56%  1 
5-12% 
8—18% 
1-  2% 

5—12% 

■86% 

^  14% 

14—48%    ] 
7—24% 
4—14% 
2-  7% 

2—  7% 

^86% 
[  14% 

2—33%  ] 
2—33%       83% 
1-17%  J 
0              1 

17% 
1-17%  J 

1-14%  1 
0 

2—29% 
0 

4-57%  , 

Much  improved . . . 

Improved 

Stationary 

Progressive      and 
died 

43% 
57% 

Total 

44    (51%) 

29    (34%) 

6   (7%) 

7   (8%) 

Table  XII  (Continued). — Relation  op  Result  and  Temperature. 


Arrested 

Much  improved  . 

Improved 

Stationary 

Progressive    and 
died 


Total 

Unrecorded,  7. 


Sanatorium  and 
Hospital  Cases. 


.8°  and  Under. 


10—24%  ] 
1-  2%    \ 

26—62%  J 
4—10% 

1-2% 


12% 


42    (42%) 


Dispensary  Cases. 


99°  to  99.8° 


11—29% 
1-3% 

18—49%, 
7—19% 

0 


81% 


19% 


100°  to  100.8° 


1-7% 
3—21% 
5—36% 
3—22% 

2—14% 


64% 


36% 


37    (37%) 


14   (14%) 


101°  and  Over. 


2—29%   1 

0  \  71% 

3—42% 

0  ) 

29% 
2—29%   J 


7      (7%) 


Only  extremely  high  temperatures  (101°  F.  and  over)  appear  to  have  any 
prognostic  significance,  and  then  only  when  taken  with  the  patient  at  rest. 
Up  to  100.8°  there  appears  to  be  very  little  difference  in  the  results,  about 
an  equal  proportion  of  cases  improving  in  those  over  and  those  under  99.8°  F. 

Sputum. 
TABLE  XIIL— RELATION  OF  RESULT  AND  SPUTUM  EXAMINATION. 


Arrested 

Much  improved 

Improved 

Stationary 

Progressive  and  died. 


Total 

Unrecorded,  43. 


Tubercle  Bacilli 
Present. 


10—30.5%  ] 

3—  9.0%       54.5% 

5—15.0% 

1—  3.0%  \ 
14—42.5%  /  45.5% 


33    (22%) 


Tubercle  Bacilli 
Absent   or  No   Ex- 
pectoration. 


38—33.6%  1 
13—10.0%    \  87.2% 
51—43.6% 
12—  9.0%  \ 
3—  3.8%  /  12.8% 


117    (78%) 


PROGNOSIS   IN   CHILDREN    UNDER   FIFTEEN. — CRAIG. 


663 


Out  of  150  cases  tubercle  bacilli  were  present  in  33  (or  22  per  cent.).  Of 
the  remaining  117  cases  a  certain  proportion  had  no  expectoration,  while  in 
the  others  the  examination  was  negative.  The  presence  of  tubercle  bacilli 
had  no  effect  on  the  result,  the  number  improving  and  not  improving  being 
about  the  same,  wdth  a  very  slight  majority  in  favor  of  the  former. 

Of  the  cases  in  which  the  bacilli  were  absent  or  there  was  no  expectora- 
tion, a  much  greater  number  of  cases  showed  improvement. 

The  absence  of  tubercle  bacilli  would,  therefore,  appear  to  be  in  the 
patient's  favor;  the  presence  of  the  bacilli  appears  to  have  no  effect  on  the 
result  one  way  or  the  other. 

Urine. 
TABLE  XIV.— RELATION  OF  RESULT  AND  URINE  EXAMINATION. 


Normal. 

Abnormal. 

Albumin. 

Casts. 

Albumin 

AND 

Casts. 

Arrested 

Much  improved. 

Improved 

Stationary 

Progressive   and 
died 

44—41%  1 
14—12%    \  86% 
36—33%  j 

8-  8%  ] 

14% 

7-  6%  J 

&-23%  ] 
1-  4%       69% 
11—42%  j 

1-  4%  1 

31% 
7—27%  J 

4 
1 
9 
0 

5 

1 
0 
1 
0 

2 

1 
0 

1 
1 

0 

Total 

Unrecorded,  58. 

109   (80%) 

26    (20%) 

19 

4 

3 

A  study  of  the  results  of  urine  examination  reveals  an  exceedingly  high 
proportion  of  cases  in  which  there  was  some  abnormality.  A  comparison 
of  the  findings  w4th  a  series  of  cases  of  over  fourteen  years  of  age  shows  that 
abnormalities  of  the  urine  occur  in  only  about  one-half  the  proportion  of 
cases  under  fourteen,  as  compared  with  the  older  cases  of  tuberculosis.  Pre- 
vious writers  have  called  attention  to  this  frequency  of  urinary  abnormalities 
in  tuberculous  subjects. 

The  cases  in  which  some  abnormality  was  present  show  a  rather  high 
proportion  of  "improved" — much  larger  than  one  would  expect  to  find, 
though  not  so  high  as  in  the  cases  in  which  the  urine  was  normal.  The 
presence  of  albumin,  casts,  or  albumin  and  casts  does  not  appear  to  have  any 
great  prognostic  significance  in  children;  their  absence,  however,  being  in 
the  patient's  favor. 


664 


SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 


Complications. 
TABLE  XV.— RELATION  OF  RESULT  AND  COMPLICATIONS. 


Tuberculous. 

Adenitis. 

Bone 
Lesion. 

Skin 
Lesion. 

Peritonitis. 

Laryngitis. 

Enteritis. 

Meningitis. 

Arrested 

Much  improved  . 

Improved 

Stationary 

Progressive 

Died 

5 
0 
5 
1 
1 
0 

1 
0 
3 
1 
0 
0 

1 

0 
1 
0 
0 
0 

0 
0 
2 
0 
0 
0 

0 
0 
0 
0 
0 
2 

0 
0 
1 

0 
0 

1 

0 
0 
0 
0 
0 
1 

12 

5 

2 

2 

2 

2 

1 

Table  XV  (Continued). — Relation  and  Result  of  Complications. 


Arrested 

Much  improved 

Improved 

Stationary 

Progressive.  . .  . 
Died 


Pleurisy. 


NON-TUBEBCULOUS . 


Otitis 
Media. 


Mitral  In- 
sufficiency. 


Epilepsy. 


Empyema. 


In  addition  to  the  tabulated  cases  tetany,  keratitis,  cardiac  dilata- 
tion, phlyctenular  conjunctivitis,  and  taenia  saginata  were  each  present 
once. 

The  complications  were  so  few  in  number  and  appeared  to  have  so  little 
effect  upon  the  result  that  no  special  reference  will  be  made  to  them,  beyond 
calling  attention  to  the  fact  that  the  two  cases  of  tuberculous  laryngitis  and 
the  case  of  tuberculous  meningitis  ended  fatally. 


Method  of  Treatment. 
In  estimating  the  results  of  treatment  in  different  institutions  the  stage 
of  disease  must  be  taken  into  consideration.     The  sanatorium  accepts  only 
early  cases,  the  hospital  only  advanced  cases,  while  the  dispensary  treats 
both  classes  of  cases. 


PROGNOSIS   IN   CHILDREN   UNDER   FIFTEEN. — CRAIG.  665 

TABLE    XVI.— RELATION    OF    RESULT   AND    METHOD    OF   TREATMENT. 


Arrested 

Much  improved 

Improved 

Stationary 

Progressive  and  died 


Stage  I. — Incipient. 


Sanatorium. 


17—65% 
5-20%    \  96% 
3—11% 

0        ""  I   ■*"/<' 


Dispensary 


^«  j     4% 


11—23%  ] 

2—  5%  \  85% 

2&-57%  I 

7-15%  1  15^ 

0  /  ^^/<^ 


Hospital. 


0 
0 

1—100% 

0 

0 


26 


46 


Table  XVI  (Conh'ntted).— Relation  of  Result  and  Method  op  Treatment. 


Arrested 

Much  improved 

Improved 

Stationary 

Progressive  and  died 


Stage  II. — Modehately  Advanced. 


Sanatorium. 


97% 


21—55% 
8—21% 
8—21% 
1-  3%  \     3^^ 


38 


Dispensary . 


5—13%  ] 

3—  8%  85% 

25—64%  I 

5      13%  \    f  cor 

1—  2%  /   ^^/'' 


39 


Hospital. 


0 
0 
0 
0 
1—100% 


Table  XVI  (Continued). — Relation  of  Result  and  Method  op  Treatment. 


Arrested 

Much  improved 

Improved 

Stationary 

Progressive  and  died 


Stage  III. — Fab  Advanced. 


Sanatorium. 


1-20%  ] 

0  40% 
1—20% 

1  20%  \  f^f^c/ 
2—40%  /  ^^^"^ 


Dispensary. 


0  1 

0 

3-42% 
2—29% 
2—29%  / 


42% 
58% 


Hospital. 


6—76%  / 


24% 
76% 


The  cases  in  Stage  I  and  Stage  II  appear  to  do  somewhat  better  under 
sanatorium  than  under  di.spensary  treatment.  While  not  so  great  as  one 
would  expect,  the  difference  between  the  two  methods  of  treatment  is  still 
quite  distinct.  The  cases  in  Stage  III  do  equally  well  in  the  sanatorium  and 
dispensary,  what  little  difference  is  noted  being  in  favor  of  the  dispensary. 
It  must  be  understood  that  these  figures  refer  only  to  cases  in  the  poorest 


666 


SIXTH   INTERNATIONAL  CONGRESS   ON   TUBERCULOSIS. 


circumstances.  The  difference  in  the  results  between  the  cases  treated  in 
the  sanatorium  and  those  treated  in  their  homes  would,  perhaps,  not  be  so 
great  if  the  patients  were  of  a  higher  class. 

General  Results  in  Children. 
TABLE  XVII.— RELATION  OF  RESULTS  IN  CHILDREN  AND  ADULTS. 


Phipps  Institute. 


Fifteen  Years  and 
Over. 


Under  Fifteen 
Years. 


White  Haven  Sana- 
torium. 


Fifteen  Years  and 
Over. 


Arrested 

Much  improved 

Improved 

Unimproved . . . 
Died 


50—  2%  1 

43% 
1243—41%    I 
1224—41%  \  .^oi 
484—16%  /  ^'/« 


16—16%  \ 
6-  5%   [ 
56—56% 
19—19%  \ 

5—  4%  / 


77% 
23% 


548 
492 
954—42% 

277—12%, 
23—  \% 


24%  1 
21%    \  87% 


13% 


3001 


102* 


2294 


Table  XVII  (Continued). — Relation  of  Results  in  Children  and  Adults. 


Arrested 

Much  improved 

Improved 

Unimproved . . . 
Died 


White  Haven 
Sanatorium. 


Under  Fifteen 
Years. 


39—56% 
13—19% 

12—18% 
4—  6% 
1-  1% 


93% 

7% 


69* 


Combined. 


Fifteen  Years  and 
Over. 


598—11%  ] 

492—  9%       62% 
2197—42%  J 
1501—29%  \  OCC7 

507—  9%  /  '^^/'^ 


Under  Fifteen 
Years. 


5295 


67—35%  1 
19—10% 
73—38% 
26—13%  \ 
8-  4%  / 


83% 
17% 


193 


A  comparison  of  the  results  obtained  in  patients  of  fifteen  years  and  over 
with  the  results  in  the  series  of  cases  here  under  consideration  reveals  some 
rather  interesting  facts.  The  figures  indicate  that  a  relatively  greater 
number  of  children  under  fifteen  showed  improvement  than  was  the  case 
in  those  of  fifteen  years  and  over.  The  difference  in  the  cases  of  the  two 
series  treated  at  the  Phipps  Institute  was  very  striking.  It  has  been  shovm 
that  advanced  cases  in  children  did  not  do  nearly  so  well  as  similarly  ad- 
vanced cases  in  adults.  Unfortunately,  it  is  impossiljle  to  show  this  differ- 
ence graphically.  The  facts  already  brought  out,  however,  demonstrate 
this  fairly  well. 

*  Twenty-two  cases  not  considered,  as  they  were  treated  in  both  institutions. 


PROGNOSIS   IN   CHILDREN   UNDER   FIFTEEN. — CRAIG. 


667 


Ashby  and  Wright*  have  stated  the  matter  very  clearly:  "In  tliis  stage 
(early)  children  perhaps  more  often  than  adults  improve  under  treatment  and 
a  careful  hygiene  and  maybe  restored  to  perfect  health;  there  is  abundant 
evidence  to  demonstrate  this."  Pfaundler  and  Schlossman,  in  their  "  Hand- 
buch  der  Ivinderheilkunde,"  state  that  the  prognosis  in  chronic  pulmonaiy 
tuberculosis  is  not  bad  if  the  disease  is  in  an  early  stage,  although  they 
believe  that  permanent  cures  are  seldom  encountered,  the  disease  being 
likely  to  manifest  itself  later.  As  to  the  permanency  of  the  results  in  the 
present  series  of  cases  not  much  can  be  said,  as  we  have  been  able  to  obtain 
information  on  this  point  in  only  few  cases,  which  give  the  figures  no  value. 

Many  children  come  under  observation  in  whom  the  general  condition 
of  the  patient,  together  with  the  histoiy,  indicates  the  presence  of  tuber- 
culosis, but  in  whom  it  is  ver}'-  difficult  to  demonstrate  any  pulmonary 
lesion.  Their  condition  corresponds  more  closely  to  the  "  pretuberculous 
stage"  of  the  French  writers.  The  series  of  cases  under  consideration 
probably  contains  a  certain  number  that  could  be  properly  grouped  in  this 
class.  This  may  account  to  some  extent  for  the  extremely  good  results 
obtained.  We  do  not  feel,  however,  that  this  affects  the  findings  in  the 
slightest  degree.  With  the  knowledge  of  the  very  excellent  results  to  be 
obtained  in  these  cases  we  should  more  than  ever  be  on  our  guard  in  our 
examination  of  children. 


TABLE  XVIII.— RELATION  OF  RESULT  AND  PROGNOSIS. 


Favorable. 


Doubtful. 


Unfavorable. 


Arrested 

Much  improved 

Improved 

Stationary 

Progressive  and  died 

Total 


58—43%  1 
15—11% 
51—38% 
7-  6%  \ 
3-  2%  / 


92% 


8% 


2-7% 
2—7% 
15—56%, 
6—22%, 
2—8% 


70% 


30% 


25% 


^10% 
0 

3—15% 
3—15% 
12—60%  /  75% 


134    (74%) 


27    (15%) 


20   (11%) 


A  study  of  the  foregoing  table  shows  that  with  our  present  knowledge 
we  are  able  to  make  a  fairly  accurate  prognosis.  Only  a  very  small  per- 
centage of  those  in  whom  a  favorable  prognosis  had  been  made  failed  to 
improve,  and  in  three-fourths  of  those  in  whom  the  prognosis  was  unfavor- 
able the  results  were  unfavorable.  In  a  fairly  large  number  of  cases  the 
prognosis  was  doubtful. 

From  the  facts  brought  out  by  a  study  of  the  foregoing  we  would  arrive 
at  the  following  conclusions: 

1.  Children  under  five  years  of  age  do  not  respond  to  treatment  as  readily 

*  "The  Diseases  of  Children,"  edited  by  Northrup. 


668  SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

as  those  over  this  age,  the  results  improving  slightly  with  the  age  of  the 
patient. 

2.  White  children  appear  to  do  somewhat  better  than  colored;  in  the 
present  series  of  cases,  however,  the  latter  showed  the  same  proportion  with 
disease  arrested. 

3.  The  amount  of  pulmonary  involvement  gives  the  best  indication  in 
regard  to  prognosis.  No  case  in  which  only  one  apex  is  involved  should 
become  "progressively  worse"  or  "die."  Only  a  very  small  proportion  of 
these  cases  fail  to  improve.  We  cannot  expect  improvement  in  any  case  in 
which  more  than  two  lobes  are  involved  with  cavity  formation;  the  great 
majority  of  these  cases  either  become  "progressively  worse"  or  die. 

4.  A  history  of  tuberculosis  in  the  parents  has  absolutely  no  influence 
upon  the  prognosis  either  one  way  or  the  other. 

5.  Next  to  the  amount  of  involvement,  the  pulse-rate  gives  the  most 
valuable  information  from  the  standpoint  of  prognosis.  To  be  of  most 
value,  the  pulse  should  be  taken  with  the  patient  at  rest.  When  taken  under 
these  conditions  no  patient  with  a  pulse  of  80  or  under  should  become  "pro- 
gressively worse"  or  die.  Seventy  per  cent,  of  these  cases  show  "disease 
arrested."  With  a  rate  over  120  we  cannot  expect  either  "  arrest  of  disease" 
or  "much  improvement." 

6.  The  respiratory  rate  gives  also  very  valuable  information.  With  a 
respiratory  rate  of  24  (at  rest)  or  under,  only  2  per  cent,  fail  to  improve. 
With  a  rate  above  32  no  improvement  can  be  looked  for  in  an  uncomplicated 
case. 

7.  The  temperature  seemed  to  have  very  little  value  except  that  a 
temperature  of  101°  F.  and  over  seemed  to  have  an  unfavorable  significance. 

8.  The  absence  of  tubercle  bacilli  from  the  sputum  and  a  normal  urine 
are  favorable  indications.  The  presence  of  the  bacilli  in  the  sputum  and 
the  presence  of  albumin  or  casts  in  the  urine  cannot,  however,  be  considered 
as  veiy  unfavorable  signs. 

9.  Cases  in  Stages  I  and  II  do  slightly  better  under  sanatorium  treat- 
ment.    The  cases  in  Stage  III  do  equally  well  in  sanatorium  and  dispensary. 

10.  The  results  in  children  under  fifteen  years  are  very  much  better  than 
in  patients  of  fifteen  years  and  over.  This  does  not  apply  to  cases  with 
extensive  involvement,  which  do  not  do  as  well  as  the  older  cases. 

On  examining  the  records  it  was  found  that  there  were  only  four  cases 
in  which  what  might  be  called  ideal  conditions  existed.  These  cases,  in 
other  words,  had  only  one  apex  involved,  the  pulse  was  80  or  under,  the 
respirations  were  24  or  under,  they  were  white,  between  the  ages  of  ten  and 
fourteen,  were  treated  in  a  sanatorium,  and  the  urine  and  sputum  were 
negative.  They  all  showed  disease  arrested.  Curiously  enough,  three  out 
of  the  four  gave  a  history  of  tuberculosis  in  the  parents. 


PROGNOSIS   IN   CHILDREN   UNDER   FIFTEEN. — CRAIG.  669 

El  Pronostico  de  la  Tuberculosis  Pulmonar  en  los  Ninos  Menores  be 
Quince  Anos. — (Craig.) 

Este  articulo  es  basado  sobre  el  estuclio  de  193  casos  de  tuberculosis 
pulmonar  en  los  ninos,  la  edad  es  de  16  meses  a  14  anos.  Se  presentan 
cuadros  de  comparacion  de  los  resultados  de  la  condicion  del  paciente  cuando 
este  por  primera  vez  fue  observado. 

Se  da  consideracion  especial  en  cuanto  al  sexo,  raza,  color,  duracion  de 
la  enfermedad,  extension  de  la  afeccion  tuberculosa,  frecuencia  del  pulso 
y  de  la  respiracion,  temperatura,  examen  del  esputo  y  de  la  orina,  com- 
plicaciones,  metodos  del  trataniiento  (en  sanatorios,  dispensarios  6  en  los 
hospitales  dela  ciudad),  y  se  comparan  los  resultados  con  aquellos  obtenidos 
en  los  adultos. 

La  cantidad  de  la  extension  de  la  enfermedad  dio  la  infoi-macion  mas 
exacta  en  cuanto  al  pronostico.  Entre  los  casos  en  los  cuales  uno  6  dos 
lobulos  estaban  afectados  con  la  formacion  de  cavidades,  6  la  afeccion  de 
dos  6  mas  lobulos,  con  la  formacion  de  cavidades  6  sin  esta,  en  ninguno 
de  los  casos  fue  el  curso  de  la  enfermedad  detenido  6  mejorado. 

Segundo  en  importancia  fue  la  frecuencia  del  pulso.  En  ninguno  de 
los  pacientes  con  un  pulso  de  80  por  minuto  6  menos,  la  condicion  de  la 
enfermedad  fue  empeorada  o  fallecio,  y  en  ninguno  de  los  pacientes  con 
un  de  120  por  minuto  fue  el  proceso  de  la  enfermedad  detenido  6  majorado. 

La  frecuencia  de  la  respiracion  dio  tambien  informaciones  valiosas. 
Ninguno  de  los  otros  factores  dio  una  indicacion  positiva. 

Los  resultados  en  los  ninos  de  una  edad  mayor  fueron  los  resultados 
un  poco  mas  favorables  que  en  los  mas  jovenes,  y  los  casos  tratados  en  los 
sanatorios  dieron  resultados  un  poco  mejor  que  los  tratados  en  los  dispensarios 
u  hospitales. 

Los  resultados  en  los  ninos  fueron  mejores  que  en  los  adultos  cuando 
la  enfermedad  no  fue  muy  extensa,  mas  no  tan  bien  en  el  estado  avanzado 
de  la  afeccion. 


Le  Pronostic  dans  la  Tuberctilose  pulmonaire  chez  les  Enfants  audessous 
de  quinze  ans. — (Craig.) 

Get  article  est  base  sur  I'etude  de  193  cas  de  tuberculose  pulmonaire 
chez  les  enfants,  d'ages  variant  entre  16  mois  et  14  ans.  On  donne  des 
tables  comparant  les  resultats  avec  la  condition  des  malades  des  le  moment 
qu'on  commenga  k  les  observer. 

Les  aspects  sp^ciaux  considdr(5s  sont:  le  sexe,  I'age,  la  race,  la  couleur, 
la  durde  de  la  maladie,  jusqu'a  quel  point  les  poumons  dtaient  atteints, 
le  degre  de  la  maladie,  la  source  d'infection,  le  taux  du  pouls  et  de  la  respira- 
tion, la  temperature,  I'examen  du  sputum  et  de  I'urine,  les  complications, 


670  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

la  methode  de  traitement  (sanatorium,  dispensaire,  ou  hopital  de  la  ville), 
et  comparaison  avcc  les  resultats  obtenus  chez  les  adultes. 

L'etendue  de  raffection  pulmonaire  donna  le  renseignement  le  plus 
siir  au  point  de  vue  du  pronostic.  Dans  les  cas  avec  un  ou  deux  lobes 
affectes,  avec  formation  de  cavites,  ou  avec  plus  de  deux  lobes  affectes, 
avec  ou  sans  formation  de  cavites,  on  n'a  dans  aucun  cas  "arrets"  ou 
"amc'liore  beaucoup"  la  maladie. 

Second  en  importance  etait  le  taux  du  pouls.  Nul  malade  avec  un 
pouls  de  80  ou  au-dessous  ne  devient  progressivement  pire  ni  ne  mourut; 
et  nul  malade  avec  un  pouls  de  plus  de  120  n'a  eu  sa  maladie  "arretee" 
ou  "beaucoup  amelioree." 

Le  taux  de  la  respiration  donna  aussi  des  renseignements  precieux. 
Aucun  des  autres  facteurs  ne  donna  d'indications  tres-positives. 

Les  enfants  plus  ages  donnerent  des  resultats  un  peu  meilleurs  que  les 
enfants  plus  jeunes;  et  les  cas  traites  dans  le  sanatorium  donnerent  des 
resultats  un  peu  meilleurs  que  ceux  traites  dans  le  dispensaire  ou  1' hopital. 

Les  resultats  chez  les  enfants  etaient  meilleurs  que  les  resultats  chez 
les  adultes,  quand  la  maladie  n'etait  pas  etendue,  mais  pas  si  bons  quand 
la  maladie  etait  avancee. 


Die  Prognose  der  Lungenschwindsucht  bei  Kindern  unter  dem  f  iinf  zehnten 

Lebensjahre. — (Craig.) 

Der  Artikel  grimdet  sich  auf  das  Studium  von  193  Fallen  von  Lungen- 
tuberkulose  in  Kindern,  deren  Alter  zwischen  16  Monaten  und  14  Jahren 
schwankte.  Vergleichungstabellen  der  Ergebnisse  des  Zustandes  der 
Kranken  bei  ihrem  Eintritte  in  die  Behandlung  sind  beigegeben. 

Als  besondere  Punkte  sind  betrachtet:  Geschlecht,  Alter,  Rasse,  Farbe, 
Krankheitsdauer,  Ausdehnung  der  Lungenaffektion,  Stadium  der  Krankheit, 
Quelle  der  Ansteckung,  Puis  und  Atmung,  Temperatur,  Untersuchung 
von  Sputum  und  Harn,  KompUkationen,  Methode  der  Behandlung  (Sana- 
torium, Ambulatorium  oder  stadtisches  Spital)  und  Vergleich  mit  den  bei 
Envachsenen  erlangten  Resultaten. 

Der  Umfang  des  Ergriffenseins  ergab  die  am  meisten  genaue  Auskunft 
von  dem  prognostischen  Standpunkte.  Unter  den  Fallen,  wo  zwei  Lappen 
mit  Kavernenbildung  ergriffen  waren,  oder  wo  mehr  als  zwei  Lappen  ergriffen 
waren,  mit  oder  ohne  Kavernen,  war  kein  einziger,  in  dem  die  Krankheit 
"gehemmt"  oder  "viel  gebessert"  wurde. 

Nachst  in  Bedeutung  war  die  Pulszahl.  Kein  Patient  mit  80  oder 
weniger  Pulsschlagen  wurde  schlimmer  oder  starb,  und  in  keinem  Patienten 
mit  mehr  als  120  Schlagen  wurde  die  Ej-ankheit  "gehemmt"  oder  "viel 
gebessert." 


HYGIENE    OF   THE    MOUTH,   NARES,   PHARYNX, 

INTESTINE,  SKIN,  MUCOUS  MEMBRANE  IN 

GENERAL,  LYMPH  BODIES,  LUNGS;  THE 

PREVENTION  OF  COLDS. 

By  Noble  P.  Barnes, 

Washington,  D.  C. 


If  attending  to  seemingly  little  things — things  frequently  neglected  and 
things  approaching  godliness— is  important,  then  hygiene  of  the  mucous 
membranes  must  be  regarded  as  a  consequential  requisite  in  the  prevention 
and  cure  of  disease. 

In  the  first  place,  a  mucous  membrane  to  be  clean  and  healthy  must 
have  free  drainage.  Therefore  in  the  very  beginning  the  adenoid  vegeta- 
tions and  the  enlarged  tonsils  that  are  present  in  a  majority  of  tuberculous 
children  must  be  promptly  and  completely  removed. 

Frequent  tonsillotomies  may  to  a  degree  relieve  obstruction,  but  the 
decapitated  tonsil  becomes  the  submerged,  partly  concealed  old  fort  that 
harbors  various  organisms  and  affords  an  open  path  for  the  invasion  of  the 
tubercle  bacillus.  Notliing  short  of  enucleation  of  tliis  degenerated  and 
diseased  structure  will  permit  a  healthy  mucosa  to  develop  at  that  point, 
and  only  by  complete  adenectomy  and  tonsillectomy  will  the  turbinates 
become  reduced  to  their  normal  size,  free  drainage  of  the  nasal  mucosa  be 
established,  and  proper  breathing  maintained. 

Only  by  securing  free  drainage  and  free  air-space  in  the  nasal  cavity  can 
we  hope  for  the  relief  and  cure  of  ear  disturbances,  recovery  of  diseased 
pulmonary  and  gastro-intestinal  mucous  membrane,  or  arrest  and  non- 
recurrence  of  a  tuberculous  process. 

Having  obtained  these  first  measures,  the  upper  air-passages  will  usually 
take  care  of  themselves,  unless  a  deflected  septum,  bony  spurs,  polypi,  or 
chronically  enlarged  turbinates  demand  additional  operative  measures. 

If  the  mucosa  is  thickened,  the  employment  of  mild  alkaline  antiseptic 
solutions,  followed  by  mentholated  albolene,  will  help  to  effect  a  healthy 
condition. 

When  possible,  and  especially  in  older  children,  laryngoscopic  examina- 
tions should  be  made,  as  a  local  infection  that  might  be  the  primary  cause 
of  the  cough  and  hemoptysis  may  in  this  way  be  discovered. 

671 


672  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

Besides  the  usual  local  treatment,  rest  to  the  involved  structures  is 
imperative.  In  the  event  of  an  actual  lesion  or  in  simple  catarrhal  con- 
ditions of  the  air-passages  nebulization  with  aromatic,  antiseptic  oils, 
blended  to  produce  a  pleasant  and  sootliing  effect,  is  of  undoubted  value. 

The  morning  toilet  of  those  who  possess  sensitive  mucous  membranes 
and  who  inhale  city  dust  should  include  the  employment  of  a  non-irritating 
nasal  douche  and  a  cold-water  gargle  following  the  usual  soap  and  brush 
to  the  teeth,  and  gradually  cooling  shower-bath.  A  free  exchange  of  air 
in  the  lungs  is  next  in  order,  the  method  of  effecting  tliis  depending  upon  the 
physical  condition,  and,  lastly,  inhalations,  for  five  or  ten  minutes,  of 
mentholated  aromatic  oils. 

During  this  time  much  of  the  mucus  collected  in  the  larynx,  trachea, 
and  bronchi  will  be  expelled.  This  means  better  appetite,  improved  diges- 
tion, and  less  nausea  from  mucus-lifting  after  breakfast.  Besides  these 
local  measures  for  the  restoration  of  respiratory  mucosa,  the  one  drug, 
where  its  use  is  not  contraindicated,  that  will  assist  in  promoting  a  healthy 
condition  is  iron  iodid,  usually  given  in  small  tonic  rather  than  alterative 
doses. 

An  active  inflammatory  process  in  any  location  demands  rest  of  the 
affected  part,  and  in  no  instance  is  it  needed  more  than  in  a  lung  involved 
in  an  acute  tuberculous  process.  Here  lung  dilatation  as  the  result  of  exer- 
cise or  high  altitude  will  not  only  prevent  healing  and  scarring  and  interfere 
with  the  formation  of  a  protective  membrane  to  institute  caseation  and 
calcification,  but  will  favor  further  invasion  of  lung  tissue  and  induce 
hemoptysis.  After  the  inflammation  has  subsided  and  the  disease  has 
become  quiescent,  gradual  expanding  of  the  lung  should  be  attempted, 
always  under  the  direction  of  a  competent  observer. 

If  judiciously  applied,  physical  training  will  yield  excellent  results. 
Removal  to  a  stimulating  climate  may  benefit  the  milder  forms  of  the  disease, 
but  prolonged  exercise  or  overwork  may  result  in  impairment  of  both  lungs 
and  body. 

In  practising  lung  gymnastics  two  precautions  should  be  observed: 
First,  never  expand  the  chest  beyond  the  degree  of  comfort,  or  there  is 
danger  of  tearing  open  old  wounds  or  of  rupturing  air-cells.  The  latter 
condition  in  itself  is  not  infrequently  followed  by  infection,  as  has  been  often 
observed  in  athletes.  Second,  expel  the  air  through  the  nose  instead  of 
through  the  mouth  or  puckered  lips,  as  is  practised  by  most  teachers  of 
physical  culture,  for  the  reasons  that  the  turbinates  are  cooled  by  inhalation, 
warmed  by  exhalation,  and  that  dust  caught  upon  the  vibrissas  and  mucous 
membrane  will  be  blown  out  instead  of  drawn  further  in. 

Only  second  in  importance,  and  not  seldom  of  primary  importance,  is 
the  mucous  membrane  of  the  digestive  tract.    As  has  been  shown  in  recent 


PREVENTION    OF  COLDS. — BARNES.  673 

experiments,  it  is  quite  as  common  a  route  for  tuberculous  invasion  in 
infants  and  young  children.  Besides  the  organisms  that  may  be  carried 
to  the  mouth  by  infected  food  and  by  unclean  hands  and  toys,  the  patho- 
genicity of  the  bovine  tubercle  bacillus  in  children  is  to-day  an  established 
fact. 

Hess,^  in  reviewing  the  cases  of  primary  mesenteric  gland  tuberculosis 
in  which  the  type  of  bacillus  has  been  differentiated,  demonstrated  that  over 
60  per  cent,  have  been  caused  by  the  bovine  type.  Among  children  this 
type  greatly  prevailed,  whereas  in  adults  the  majority  of  infections  were 
with  the  human  variety.  There  is  strong  evidence  that  these  organisms 
are  as  similar  as  the  different  families  of  the  human  race,  and  are  only 
altered  by  environment.  In  this  event  most  tuberculous  infection  must 
occur  during  the  milk-feeding  age. 

Certainly  the  only  rational  method  of  keeping  the  digestive  tract  clean 
is  to  prevent  the  introduction  of  infection.  The  milk  may  either  be  pas- 
teiu-ized  and  the  organisms  destroyed,  preferably  by  a  process  of  lower 
temperature  and  aeration,  or,  as  suggested  by  Gunn,^  a  breed  of  cattle  that 
is  immune  to  tuberculous  disease  may  be  reared.  We  can  give  sterile  animal 
broths  and  other  foods  that  we  know  to  be  clean;  all  this  is  "love's 
labor  lost"  unless  we  can  prevent  the  numberless  methods  of  infections 
that  come  from  a  lack  of  correcting  the  little  things. 

The  abominable  pacifier,  rubber  or  rag,  is  in  the  nurse's  or  mother's 
mouth,  then  in  the  baby's,  then  on  the  floor,  and  again  in  the  baby's.  In  this 
cycle  the  child  can  receive  into  its  digestive  tract  thousands  of  organisms. 
Furthermore,  by  the  sucking  of  these  articles  the  mouth  and  palate  may 
become  deformed,  a  constant  hj'peremia,  congesting  the  post-nasal  and 
tonsillar  glands  is  present,  producing  the  adenoid  vegetations,  and,  lastly, 
the  habit  of  having  sometliing  in  the  mouth  is  created.  Thus  by  the  time 
the  child  is  old  enough  to  walk,  and  up  until  school  hfe,  all  manner  of  tilings, 
from  strings  to  pennies,  find  a  resting-place  in  the  mouth,  usually  inserted 
there  by  dirty  fingers.  From  school  life  on  this  habit  continues,  and 
gum-chewing,  "all-day  suckers,"  pencil-wetting,  and  nail-nibbling  are  the 
result. 

When  we  are  confronted  with  an  infected  digestive  mucosa,  we  must, 
in  a  great  measure,  depend  upon  the  hydrochloric  acid  of  the  stomach.  If 
it  is  deficient,  we  must  supply  it.  This  acid  is  nature's  antiseptic  for  the 
stomach,  and  stimulates  the  flow  of  nature's  intestinal  antiseptic,  the  bile. 
Internal  antiseptics  should  be  administered  to  these  cases,  as  well  as  to 
those  who  are  too  young  to  prevent  the  secretions  from  the  respiratory 
membrane  from  slipping  into  the  stomach. 

Another  evidence  of  neglect  in  the  little  things  concerning  the  gi'owing 
child  is  the  lack  of  attention  that  is  paid  to  the  teeth.     Practically  all 
VOL.  II — 22 


674  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

children  for  a  considerable  period  absorb  into  their  lymph-channels  and 
carry  into  their  stomachs  hosts  of  organisms.  Decaying  teeth  should  be 
cleansed  and  filled  or  extracted.  The  popular  belief  that  the  first  teeth 
must  not  be  disturbed  for  fear  of  interfering  with  the  second  set  must  be 
dispelled. 

There  is  just  one  thing  to  do  with  tuberculous  lymph  bodies,  when  they 
can  be  reached;  and  that  is  to  effect  prompt  and  complete  removal  of  the 
chain.  Seventy-five  per  cent,  of  school-children  will  exhibit  enlarged  lymph- 
atics, due  to  excessive  metabolism,  but  these  can  be  reduced  by  diet, 
hygiene,  and  proper  medication.  Sodium  salicylate  and  iron  iodid  are 
appropriate  remedies. 

Wilder^  states  that  "the  earlier  statistics  as  to  frequency  of  tuberculosis 
of  the  eye  must  be  regarded  as  rather  misleading";  as  Groenouw  suggests: 
"  With  a  growing  knowledge  of  the  subject  the  number  of  cases  of  tuberculosis 
of  the  eye  is  naturally  increasing.  Brejski  holds  that  10  per  cent,  of  cases  of 
parenchymatous  keratitis  are  tuberculous.  Diez*  estimates  the  percentage 
as  high  as  50.  Haas  claims  that  as  high  as  50  per  cent,  of  all  cases  of  iritis 
are  tuberculous.  ]\Iany  observers,  like  Greef,  Mickel,  and  others,  find  by 
histological  examination  evidence  of  tubercle  in  the  uveal  tract  that  was  not 
apparent  during  life."  This  suggests  the  need  of  a  prophylactic  eye  toilet, 
which  can  be  carried  out  with  the  usual  morning  and  evening  washings,  and 
consists  of  the  application  of  non-irritating  antiseptic  lotions  by  means  of 
the  convenient  eye-cup. 

Ear  infection  usually  occurs  from  within,  being  an  extension  of  inflam- 
mation from  the  nasal  cavity,  due  to  lack  of  drainage  and  air-space.  When 
these  faults  are  corrected,  and  cleanliness  of  the  external  auditory  canal  is 
maintained,  further  trouble  will  be  avoided.  Examination  of  the  infant's 
ear  should  be  a  routine  procedure.  If  this  is  not  done  the  careless  observer 
may  overlook  a  beginning  otitis  and  treat  the  baby  for  almost  anything,  from 
colic  and  bronchitis  to  perverted  disposition  and  meningitis. 

To  do  the  things  that  have  here  been  enumerated;  to  keep  the  mucous 
membranes  clean  and  healthy,  means  in  itself  one  of  the  first  steps  toward 
preventing  the  so-called  "taking  cold."  The  expressions  "catching  cold," 
"cold  in  the  head,  chest,  or  back,"  mean  absolutely  nothing  to  the  trained 
mind.  If  the  mucous  membranes  are  free,  open,  well  drained,  and  healthy, 
there  will  be  no  army  of  organisms  waiting  for  a  lowering  of  resistance  by 
exposure  to  atmospheric  changes,  fatigue,  or  hunger  to  operate  in  the  pro- 
duction of  a  rhinitis,  bronchitis,  follicular  tonsillitis,  or  rheumatism 

In  addition  to  the  hygienic  measures  mentioned  a  considerable  degree 
of  resistance  can  be  established  by  proper  bathing.  The  usual  hot  bath 
must  be  discontinued.  The  tepid,  gradually  cooling  shower,  accompanied 
by  friction,  is  to  be  preferred.     The  temperature  should  depend  upon  the 


PREVENTION    OF   COLDS. — BARNES.  675 

individual  case,  and  should  be  lowered  only  to  the  point  of  getting  good 
reaction. 

In  short,  the  measures  to  be  instituted  in  order  to  obtain  the  desired 
result,  namely,  the  "prevention  of  colds,"  are  as  follows:  Proper  hygiene 
of  the  skin  and  mucous  surfaces;  proper  hygiene  in  diet,  sleep,  and  living; 
avoidance  of  fatigue,  prolonged  hunger,  mufflers,  chest  protectors,  dust,  and 
poorly  ventilated  surroundings. 

Churches,  theaters,  and  even  schools  are  often  filled  with  hot,  germ- 
laden  air;  and  the  truant,  though  regarded  as  a  bad  boy,  must  be  credited 
with  good  sense  in  that  he  prefers  the  open  air.  No  exercise  in  the  play 
park  can  overcome  the  injury  that  accrues  from  studying  in  foul-aired 
school-rooms  or  sleeping  in  closed  apartments.  Nor  can  fresh  air  and  good 
food  overcome  disease  caused  by  defect. 

The  new  hygiene  of  to-day  should  be  taught  in  the  school;  this  does 
not  mean  that  most  stress  should  be  laid  on  the  effect  of  tobacco  and  alcohol, 
but  that  the  student  should  be  taught  that  the  avenues  of  infectious  diseases 
are  through  the  skin  and  mucous  membranes,  and  that,  consequently, 
these  must  be  kept  clean  and  healthy. 

BIBLIOGRAPHY. 

1.  Hess:  Amer.  Jour.  Med.  Sci.,  August,  1908. 

2.  Gunn:  Brit.  Med.  Jour.,  February  15,  1908. 

3.  Wilder:  Jour.  Amer.  Med.  Assoc,  vol.  xxv. 

4.  Diez:  Zeit.  f.  Augenheilkunde,  1899,  435. 


THE  EXPECTANT  TREATMENT  OF   PULMONARY  TU- 
BERCULOSIS—A  CONTRIBUTION   FROM 
ORTHOPEDIC  SURGERY. 

By  Adoniram  B,  Judson,  M.D., 

New  York. 


The  doctrine  derived  from  the  study  of  orthopedic  cases  is  that  tuber- 
culosis in  the  joints  owes  its  destructive  character  to  unfavorable  environ- 
ment and  not  to  an  inexorable  disposition  of  its  own,  which  doctrine  may  be 
extended  to  read  that  patients  affected  with  tuberculosis  of  the  lungs  will 
recover  without  treatment  if  their  environment  is  favorable. 

Aside  from  whatever  infective  quality  it  may  have,  tuberculosis  of  the 
joints,  the  worthy  rival  of  infantile  paralysis  in  the  production  of  lameness, 
is  clinically  the  expression  of  a  conflict  between  destructive  and  reparative 
forces.  After  a  period  of  advance,  the  disease  retreats.  The  cause  and 
method  of  this  benign  change  are  not  understood,  but  the  surgeon,  encour- 
aged by  the  certainty  of  its  coming,  invites  its  approach  by  mechanically 
protecting  the  affected  part  and  providing  the  best  possible  general  environ- 
ment. This  he  will  continue  to  do  until  the  nature  of  the  trouble  is  under- 
stood. When  knowledge  of  the  tuberculous  process  leads  to  its  arrest  and 
prevention,  a  portentous  medical  riddle  will  be  solved. 

In  all  sections  of  the  Congress  pulmonary  tuberculosis  will  be  very  much 
in  the  minds  of  our  colleagues  as  the  chief  burden  of  their  professional  lives. 
In  the  wide  range  of  general  medicine  it  stands  out  in  baleful  perspective. 
The  same  distinction  is  held  in  the  limited  field  of  orthopedic  surgery  by 
hip  disease.  If  nothing  can  be  done  to  promote  recovery  from  hip  disease 
except  to  correct  faulty  environment,  it  will  be  but  a  step  further  to  say 
the  same  of  pulmonary  tuberculosis. 

The  tuberculous  hip  has  been  intractable  to  all  forms  of  positive  treat- 
ment. Medication  has  not  been  neglected.  New  devices  of  minor  surgery 
are  constantly  in  the  stage  of  experimentation.  New  mechanical  methods 
have  been  counted  by  the  hundreds,  and  operative  surgery  has  been  pushed 
to  the  extreme.  Although  patients  have,  almost  without  exception,  re- 
covered, curative  treatment  has  not  been  found,  and  the  often  disappointed 
observer,  led  by  reason  and  experience,  relies  confidently  on  expectant 
treatment.     He  provides  a  local  environment  that  frees  the  affected  part 

676 


EXPECTANT  TREATMENT  OF  PHTHISIS. — JUDSON.  677 

from  disturbance,  and  seeks  a  general  environment  that  includes  abundant 
food,  innocuous  occupation,  and  sanitary  housing.  The  patient  is  thus 
assured  of  recovery  with  the  least  inconvenience  and  the  best  result  allowed 
by  the  nature  of  the  case. 

Can  pulmonary  tuberculosis  be  viewed  in  the  same  therapeutical  light? 
It  may  be  said  that  as  one  is  fatal  and  the  other  not  fatal,  recovery  from 
both  cannot  be  expected  to  follow  the  same  line  of  treatment.  Sir  Benjamin 
Brodie  said:  "Why  should  hip  disease  be  dangerous?  The  hip  is  not  a 
vital  organ,"  and  Dr.  Henry  G.  Davis,  the  leader  of  the  modern  renaissance 
of  orthopedic  surgery,  wrote:  "Medical  men  are  convinced  that  when  con- 
sumption has  once  taken  possession,  it  goes  not  out  until  the  spark  of  life 
goes  with  it."* 

The  parts  affected  have,  however,  peculiarities  of  anatomy  and  physiology 
that  make  it  reasonable  to  believe  that  the  treatment  accorded  to  one  may 
be  appUed,  mutatis  mutandis,  to  the  other.  The  lung  is  a  semi-detached, 
almost  pedunculated  organ.  The  hip  is  an  inherent  part,  interlocked  with 
other  parts  of  the  body  by  far-reaching  and  rigid  processes.  The  construc- 
tion of  the  lung  is  simple;  that  of  the  hip,  complex  and  jointed.  Lung 
tissue  is  soft  and  homogeneous,  completing  development  with  the  cry  of 
the  new-born,  whereas  the  tissues  of  the  hip  range  from  hardest  bone  to 
impalpable  synovial  membrane,  and  reach  development  in  late  adolescence. 
The  vascular  network  of  the  lung  invites  infection  and  encourages  repair, 
whereas  the  hip,  with  its  comparatively  deficient  circulation,  reluctantly 
yields  to  disease  and  reacts  so  slowly  that  a  typical  case  of  hip  disease  covers 
several  years. 

If  the  hip  rises  superior  to  tuberculous  infection,  what  forbids  the  ex- 
pectation of  signal  recovery  in  the  lung,  so  separate  from  the  rest  of  the 
body,  so  simple  in  construction,  with  rapidly  developing,  homogeneous,  and 
plastic  tissue,  so  infused  with  vascularity,  and  altogether  so  alert  and  respon- 
sive to  the  appeals  of  disease  and  recovery?  And  the  factor  of  safety  is  to 
be  considered.  If  both  lungs  were  seriously  impaired,  the  case  would  be 
fatal;  but  when  it  is  known  that  with  only  part  of  a  lung  life  may  be  in- 
definitely prolonged,  who  can  put  a  limit  to  recovery  in  a  favorable  environ- 
ment? 

It  will  be  in  order  to  note  the  environments  required  in  hip  disease  and 
consumption  respectively.  A  therapeutical  precept,  followed  alike  by 
nature  and  art,  is  the  arrest  of  the  function  of  an  inflamed  organ.  This 
is  especially  applicable  to  the  hip  endowed  with  wide  and  active  motion, 
and  no  less  applicable  to  the  lungs,  which  are  in  constant  motion.    The 

*  "Conservative  Surgery,"  1866,  p.  284.  Reprint  from  same,  "The  Curability  of 
Pulmonary  Consumption,"  p.  4.  His  views,  except  in  their  optimism,  have  little  in 
common  with  those  presented  here. 


678  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

arrest  of  motion  that  is  sought  in  the  tuberculous  hip  by  fixation  may  be 
sought  in  the  tuberculous  lung  by  the  omission  of  exercises  that  unduly 
quicken  the  breathing  and  circulation,  and  by  keeping  respiration  at  the 
minimum,  as  is  seen  in  healthy  sleep.  The  possible  volume  of  respired  air 
is  a  useful  provision  for  emergencies,  but  is  not  always  necessaiy  for  health 
and  recovery.  It  is  a  unanimous  opinion  that  the  seat  of  inflammatory 
action  must  be  protected  from  violent  disturbance.  This  protection  is 
sought  in  the  hip  by  recumbency  or  the  use  of  portable  apparatus,  and  may 
be  sought  in  the  diseased  lung  by  the  cessation  of  coughing. 

The  interesting  question  arises  whether  coughing  can  be  arrested  or 
prevented.  The  impulse  comes  from  a  congested  point  where  an  adhesive 
exudation  promptly  appears.  Coughing  destroys  this  protection,  and  a 
semifluid  secretion  soon  calls  for  renewed  efforts,  attended  by  temporary 
and  doubtful  relief  and  certain  injury  to  membranes  in  a  state  of  subacute 
inflammation  likely  to  become  chronic.  Coughing  increases  the  irritation, 
and  the  irritation  in  turn  increases  the  cough.  This  is  a  vicious  circle, 
and  certainly  suggests  the  intervention  of  reason  and  self-control.  That  the 
lungs  are  exposed  to  the  risk  of  injury  is  clear  on  a  consideration  of  the 
mechanics  of  this  muscular  convulsion.  On  occasion  the  thoracic  and 
abdominal  muscles  act  as  expulsive  organs,  and  when  they  respond  to  an 
impulse  to  cough,  their  great  power  is  displayed  in  severe  compression, 
alternating  with  sudden  release  and  agitation  of  the  whole  respiratory 
apparatus,  w^hereas  the  compressed  air  driven  through  the  tubes  recalls 
the  action  of  a  steam  pencil,  wanting  only  the  mordant  agent  to  become  an 
excoriating  sand-blast. 

It  may  not  be  doubted  that  intelligent  effort  will  in  a  measure  overcome 
this  habit,  and  in  many  cases  lead  to  its  cessation.  It  is  not  easy  to  ignore 
laryngeal  irritations  and  temptations  to  cough,  and  to  give  up  what  one 
has  been  accustomed  to  for  years.  Reform  is  a  tedious  process,  because 
it  takes  longer  to  go  up  hill  than  down.  Neither  is  it  altogether  frivolous 
to  say  that  if  you  do  not  cough  the  first  time,  you  do  not  have  any  cough. 
Expectoration,  when  imperative,  may  be  facilitated  by  assuming  for  a  mo- 
ment an  attitude  in  which  the  direction  of  the  air-passage  is  changed  from 
the  vertical  to  a  downward  inclination,  when  gravitation  and  a  little  effort 
provide  a  harmless  exit.  In  such  straits  quadrupeds,  with  their  inclined 
wind-pipes,  have  an  advantage,  as  was  seen  during  the  epizootic  that  afflicted 
American  horses  in  1872. 

The  local  treatment  of  pulmonary  tuberculosis,  based  on  orthopedic 
practice,  may  be  outlined  as  follows:  (1)  The  omission  of  whatever  unduly 
excites  respiration  and  circulation;  (2)  the  habitual  reduction  of  the  volume 
of  respired  air  to  the  minimum;   (3)  the  inhibition  of  coughing. 

Turning  now  from  local  to  general  considerations,  it  is  evident  that  a 


EXPECTANT  TREATMENT   OF   PHTHISIS. — JUDSON.  679 

favorable  general  environment  should  be  accorded  equally  to  the  hip  patient 
and  to  the  consumptive,  and,  indeed,  in  view  of  prevention,  to  every  member 
of  the  community.  The  question  of  how  to  distribute  evenly  the  advantages 
of  abundant  food,  innocuous  occupation,  and  sanitary  housing  is  calling  for 
quick  attention. 

In  passing,  I  suggest  the  possibility  of  relaxing  the  custom  that  regulates 
the  hours  of  taking  food.  Is  it  wise  to  eat  three  meals  at  short  intervals 
and  then  give  a  long  interv'al  to  fasting?  An  old  custom  of  the  navy  called 
for  the  "  meal  pennant "  at  8  bells.  Thus  the  men  had  breakfast  at  8  o'clock, 
dinner  at  12,  and  supper  at  4.  Three  meals  within  eight  hours  were  followed 
by  a  fast  of  sbcteen  hours.  The  efficiency  of  the  ship's  company  may  not 
have  been  apprecial^ly  reduced,  but  a  more  reasonable  dietary  would  have 
obsei-ved  an  even  distribution  and  the  omission  of  fasting.  In  this  connec- 
tion the  method  of  the  machinist,  when  he  gives  fuel  to  his  engine,  may  be 
recalled,  and  the  rules  that  govern  feeding  in  the  nursery  and  the  typhoid 
ward. 

It  has  been  said  that  prevailing  east  winds  and  atmospheric  moisture 
are  less  potent  as  factors  of  pulmonary  tuberculosis  than  is  parsimony. 
Tuberculosis  of  the  joints  is  especially  a  menace  to  childhood,  and  yet  in 
this  period,  when  the  vital  processes  are  at  their  best,  and  gro'ui;h  and  de- 
velopment are  active,  it  seems  that  natural  resistance  to  general  disease 
should  be  alert  and  give  protection  from  dangers  of  this  kind.  In  early 
youth  the  circulation  is  rapid  and  full.  Children  are  not  easily  deprived  of 
their  share  of  respiratory  activity.  They  are  not  given  to  introspection  and 
melancholy,  which  have  been  thought  to  favor  the  approach  of  general  or 
constitutional  diseases.  Their  habits  are  far  from  sedentary.  Their  minds 
are  free  from  worry,  and  their  bodies  from  overwork  and  long  hours,  without 
rest  and  recreation.  By  this  process  of  exclusion  their  danger  may  perhaps 
be  traced  to  some  mismanagement  of  alimentation. 

Some  unfortunates  are,  from  sad  necessity,  denied  sufficient  food.  Others 
perhaps  suffer  because  prudent  economy  finds  easy  expression  in  a  scanty 
allowance  to  the  younger  members  of  the  family,  reinforced  by  a  common  and 
not  altogether  unreasonable  belief  that  it  is  l^ad  for  a  child  to  eat  too  much. 
Overeating  may,  of  course,  induce  acute  disorders  of  brief  duration,  but,  on 
the  other  hand,  this  sort  of  prudence  may  easily  lead  to  the  more  serious 
mistake  of  opening  the  door  for  chronic  affections  by  withholding  sufficient 
nourishment.  Certain  young  parents  who  have  no  reason  for  economy  seem 
to  have  an  idea  that  the  precious  object  intrusted  to  them  has  delicate  and 
sublimated  qualities  that,  for  a  time  at  least,  exemot  it  from  the  common 
necessity  of  an  abundance  of  good  food. 

Without  experience  in  diseases  of  the  lungs,  I  am  not  so  presumptuous 
as  to  claim  too  much  for  the  therapeutical  concept  included  in  this  article, 


680  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

but  logical  inferences,  unsupported  by  experience,  may  prove  to  have  prac- 
tical value,  and  the  argument  here  ventured  will  not  be  in  vain  if  it  throws 
a  single  ray  of  light  on  a  most  important  subject. 

The  prevention  of  disease  is  a  desideratum  that,  when  acquired,  gives  to 
the  physician  the  greatest  pride  and  delight.  Next  to  that  comes  the  satis- 
faction of  recognizing  and  providing  for  the  miracle  of  recovery  by  expectant 
treatment.  It  may  be  asked  w^hat  will  be  the  status  of  the  medical  pro- 
fession when  prevention  and  expectation  shall  have  reached  the  beneficent 
extremes  so  eagerly  anticipated.  The  medical  student,  if  he  has  time  to 
read  these  remarks  on  pulmonary  tuberculosis,  will  say:  "But  where  does 
the  physician  come  in?"  My  young  friend,  he  is  not  coming  in.  His  suc- 
cessor, say,  fifty  years  from  now,  may  be  the  trained  nurse.  The  physician 
may  then  be  found  in  the  State  laboratory,  making  a  diagnosis,  or  perchance 
prescribing  absent  treatment  for  the  Martians. 


Contribucidn  de  la  Ortopedia  Quirurgica  al  Estudio  de  la  Tuberculosis. 

— (JUDSON.) 

Se  avanza  la  proposicion  que  los  pacientes  afectados  de  tuberculosis 
pueden  recuperar  y  que  nuevos  casos  pueden  prevenirse  si  el  medio  ambiente, 
local  y  general,  es  favorable.  El  argumento  se  relaciona  con  la  comparacion 
de  dos  formas  comunes  de  la  infeccion:  tuberculosis  de  la  articulacion  de 
la  cadera  y  la  tisis.  El  principio  de  que  la  primera  puede  recuperar  sin 
tratamiento  especial,  sino  simplemente  por  medio  del  mejoramiento  del 
medio  ambiente,  es  derivado  de  la  clinica  y  de  la  literatura.  Se  sostiene 
que  si  la  tuberculosis  de  la  articulacion  de  la  cadera  es  capaz  de  recuperar, 
bajo  un  punto  de  vista  de  la  Anatomia  y  Fisiologia  comparada  de  la  articu- 
lacion de  la  cadera  y  del  pulmon,  que  los  mismos,  sino  mejores  resultados, 
pueden  obtenerse  en  la  tisis.  Se  expone  un  medio  ambiente  correcto  para 
la  tisis.  Es  admitido  que  al  presente  es  imposible  proveer  para  todos,  el 
enfermo  y  el  sano,  el  medio  ambiente  deseable,  lo  cual  incluye  abundancia 
de  alimentos,  ocupaciones  inocuas  e  higiene  en  las  habitaciones,  mas  las 
observaciones  sobre  la  enfermedad  de  la  cadera  demuestran  que  el  descanso 
local  debe  procurarse  en  la  tisis  por  medio  de  la  respiracion  superficial, 
sesacion  de  la  tos  y  evitar  el  ejercicio  que  acelera  la  respiracion. 


Une  contribution  de  la  chirurgie  orthop^dique  k  l'6tude  de  la  tuberculose. 

— (JuDSON.) 

On  avance  la  proposition  que  les  malades  atteints  de  la  tuberculose 
guerissent  et  ne  subissent  pas  de  rechute  si  I'environnement  local  et  general 


EXPECTANT  TREATMENT   OF   PHTHISIS. — JUDSON.  681 

est  favorable.  L'argument  se  reduit  a  une  comparaison  entre  deux  formes 
tres  communes  de  I'infection,  la  tuberculose  de  la  hanche  et  la  tuberculose 
des  poumons.  Le  fait  que  la  premiere  forme  se  guerit  sans  traitement 
excepte  par  correction  est  base  sur  des  experiences  de  cliniques  et  sur  des 
publications  medicales.  On  pretend  alors  que  si  la  tuberculose  de  la  hanche 
se  guerit  ainsi,  I'anatomie  et  la  physiologie  comparees  du  poumon  et  de  la 
hanche  fournissent  des  raisons  suffisantes  pour  I'opinion  que  des  r^sultats 
semblables  ou  meme  meilleurs  se  produiront  dans  les  cas  de  tuberculose 
des  poumons.  L'auteur  expose  un  plan  d'entourage  correct  pour  les  poitrin- 
aires.  II  admet  qu'il  n'est  pas  possible  a  present  d'obtenir  pour  tous, 
malades  et  bien-portants,  Tentourage  general  desir^,  qui  comprend  entre 
autres  une  nourriture  abondante,  une  occupation  inoffensive  et  une  habita- 
tion sanitaire;  mais  les  observations  faites  dans  les  cas  de  maladie  de  la 
hanche  indiquent  qu'un  repos  local  devrait  etre  obtenu  dans  la  tuberculose 
des  poumons  par  une  respiration  superficielle,  par  la  cessation  de  la  toux, 
et  en  evitant  les  exercises  qui  hatent  la  respiration. 


Ein  Beitrag  aus  der  orthopadischen  Chirurgie  zum  Studium  der  Tuber- 

kulose. — (JuDsoN.) 

Es  ist  die  Voraussetzung  vorgeschritten,  dass  von  Tuberkulose  befallene 
Patienten  genesen  warden  und  dass  neue  Falle  nicht  vorkommen  werden, 
wenn  die  ortliche  und  allgemeine  Umgebung  giinstig  ist.  Die  Beweis- 
fiihrung  ist  zu  einem  Vergleiche  zweier  gewohnlicher  Formen  der  Infection, 
der  Hiifterkrankung  und  der  Schmndsucht,  zusammengebracht  worden. 
Die  Constatirung,  dass  die  erstere  ohne  Behandlung,  ausgenommen  Ver- 
besserung  der  Umgebung,  zur  Genesung  fiihrt,  ist  klinisch  und  von  der 
Literatur  abgeleitet  worden.'  Es  wird  behauptet,  dass  wenn  die  Hiifter- 
krankung besser  wird,  dass  Griinde  in  der  vergleichenden  Anatomie  und 
Physiologie  der  Lunge  und  Hiifte  vorhanden  seien,  um  den  Glauben  zu 
rechtfertigen,  dass  dieselben  und  sogar  bessere  Resultate  bei  Schwindsucht 
folgen  werden.  Fine  richtige  Umgebung  fiir  Schwindsucht  ist  sldzzirt. 
Es  wird  zugegeben,  dass  es  gegenwartig  nicht  moglich  ist,  fiir  alle,  Gesunde 
und  Kranke,  die  angestrebte  allgemeine  Umgebung  zu  sichern,  welche 
ausreichende  Nahrung,  unschadliche  Beschaftigung  und  gesundheits- 
gemasses  Wohnen  in  sich  schliesst,  aber  die  Beobachtungen  bei  der  Hiifter- 
krankung zeigen  an,  dass  bei  Schwindsucht  ortliche  Ruhe  gesichert  scin 
soUte,  durch  oberflachliches  Athmen,  das  Aufhoren  des  Hustens  und  das 
Vermeiden  von  Leibesiibungen,  die  die  Athmung  beschleunigen. 


THE  SEASHORE  AND  FRESH  AIR  TREATMENT  AT 
SEA  BREEZE  HOSPITAL 

OF  TUBERCULOUS  DISEASE  OF  THE  BONES,  JOINTS,  AND  GLANDS 

OF  CHILDREN. 

By  John  W.  Brannan,  M.D., 

New  York. 


At  the  last  International  Congress  on  Tuberculosis,  held  in  Paris  three 
years  ago,  the  subject  of  marine  sanatoriums  for  tuberculous  children  occu- 
pied an  important  place  in  the  proceedings.  Exhaustive  reports  were  pre- 
sented by  Armaingaud,  of  Bordeaux,  and  D'Espine,  of  Geneva,  and  the 
Section  on  Tuberculosis  in  Children  gave  an  entire  morning  to  the  discussion 
of  the  reports.  When  we  consider  that  there  are  upwards  of  seventy-five  such 
sanatoriums  on  the  various  sea-coasts  of  Europe,  one  of  them,  Berck,  having 
been  established  in  1861,  it  is  easy  to  understand  why  they  were  thought 
worthy  of  so  much  attention.  Armaingaud  had  collated  the  French  statis- 
tics, and  stated  that  in  France  alone  60,000  children  suffering  from  tubercu- 
losis of  the  bones  and  glands  had  been  treated  in  seaside  sanatoriums  since 
1887,  -with  59  per  cent,  of  cures  and  25  per  cent,  of  cases  decidedl}^  improved, 
making  in  all  84  per  cent,  of  favorable  results.  The  percentage  of  cures 
varied  from  32  in  Pott's  disease  to  74  in  glandular  tuberculosis.  Investi- 
gations by  several  independent  ol)servers  showed  that  in  about  three- 
quarters  of  the  cases  the  cures  were  permanent.  According  to  D'Espine, 
the  reports  from  other  countries  were  equally  encouraging,  whether  the 
sanatorium  was  located  on  the  Baltic,  the  North  Sea,  the  Mediterranean, 
the  Adriatic,  or  the  Atlantic  Ocean.  The  conclusions  of  the  Congress  were 
that  the  seashore  offered  special  advantages  for  the  treatment  of  non-pul- 
monary tuberculosis  in  children,  and  that  the  number  of  marine  sanato- 
riums should  be  increased  as  rapidly  as  possible. 

Among  the  papers  presented  at  the  Section  on  Tuberculosis  in  Children 
was  one  giving  an  account  of  the  experience  at  Sea  Breeze  Hospital  during 
the  first  fifteen  months  of  its  existence.  It  is  my  purpose  to-day  to  con- 
tinue this  report  to  the  present  time,  covering  a  period  of  somewhat  more 
than  four  years.  For  the  sake  of  clearness  it  will  be  necessary  to  include  a 
brief  summary  of  the  early  history  of  the  institution. 

682 


SEA    BREEZE   HOSPITAL. — BRANNAN.  683 

In  June,  1904,  the  New  York  Association  for  Improving  the  Condition  of 
the  Poor,  impressed  by  the  favorable  results  obtained  at  Berck  and  the  other 
marine  sanatoriums  abroad,  decided  to  establish  a  similar  hospital  at  its  sum- 
mer home,  Sea  Breeze,  on  the  beach  of  Coney  Island.  At  the  request  of  the 
Association  Mr.  John  Seely  Ward,  Jr.,  one  of  its  Board  of  ]\Ianagers,  had  visited 
the  sanatorium  at  Berck  while  traveling  in  Europe  during  the  summer  of 
1903.  It  was  Mr.  Ward's  favoraljle  report  on  his  return  that  led  the  Asso- 
ciation to  begin  its  experiment  the  following  year.  No  building  being  im- 
mediately available,  a  tent  camp  was  constructed,  of  sufficient  size  to  ac- 
commodate about  45  patients.  During  this  summer  there  were  under  treat- 
ment sixty-three  children,  who  came  either  direct  from  their  homes  in  the 
tenements  or  from  the  different  orthopedic  hospitals  of  the  city.  They 
comprised  cases  of  tuberculous  disease  of  the  spine,  of  the  hip,  knee  and 
other  joints,  as  well  as  eight  cases  of  tuberculosis  of  the  glands.  No  attempt 
was  made  at  selection.  The  disease  was  in  an  advanced  stage  in  the  great 
majorit}^  of  the  cases.  The  general  severity  is  indicated  by  the  fact  that  of 
the  63  patients,  28  had  (on  entrance)  one  or  more  open,  discharging  sinuses. 
Throughout  the  summer  the  children  passed  the  entire  twenty-four  hours 
in  the  open  air,  by  day  on  the  beach  or  in  rainy  weather  on  a  covered  plat- 
form open  on  all  sides,  by  nights  in  tent  widely  open  at  the  ends,  and  with 
windows  on  both  sides  and  in  the  roof.  The  patients  were  bathed  in  the  sea 
every  day  and  many  of  them  soon  learned  to  take  care  of  themselves  in  the 
water. 

Improvement  began  in  the  children  at  once.  When  they  came,  most 
of  them  were  pale,  languid,  rather  fretful,  with  uncertain  appetite,  and  with 
a  disinclination  to  play  or  even  to  talk.  Within  a  week  their  spirits  re- 
vived; they  slept  soundly,  awoke  with  an  appetite,  and  were  ready  to  join 
in  play.  Their  circulation  became  stronger,  their  cheeks  were  reddened  by 
the  exposure  to  the  sun,  and  the  gain  in  weight  was  almost  constant. 

When  the  autumn  came  and  the  children  could  no  longer  be  kept  in 
tents,  it  was  decided  to  take  one  of  the  buildings  of  the  summer  home  and 
make  it  over  for  hospital  purposes.  This  building,  being  detached  from  the 
others  and  furnished  with  wide,  open  porches  and  many  windows,  lent  itself 
admirably  to  the  purpose.  The  partitions  between  several  rooms  were  re- 
moved and  four  dormitories  were  thus  provided,  sufficient  to  accommodate 
about  forty-five  children.  The  entire  expense  of  the  alterations,  including 
the  installation  of  a  steam- heating  plant,  was  under  $2000. 

It  was  with  considerable  misgiving  that  we  undertook  to  continue  the 
open-air  life  of  the  children  throughout  the  winter,  though  convinced  that 
only  by  so  doing  could  we  maintain  the  improvement  that  had  been  made 
during  the  summer.  The  outdoor  treatment  of  pulmonary  tuberculosis 
in  the  adult  had  been  accepted  by  the  general  public  as  well  as  by  the  medical 


684  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

profession,  but  to  submit  delicate  children  to  the  same  conditions  may  well 
have  seemed  unwise  to  many.  But  our  courageous  superintendent,  Miss 
Alice  Page  Thomson,  after  a  visit  to  Dr.  Trudeau's  sanatorium  at  Saranac, 
instituted  an  open-air  regime,  which  has  been  followed  rigorously  and  ad- 
vantageously ever  since.  The  children  are  kept  in  the  open  air  throughout 
the  twenty-four  hours,  and  tliroughout  the  entire  year.  As  soon  as  break- 
fast is  over  the  bed-cases  are  carried  out  and  placed  in  cribs  on  the  open 
porches,  which  give  right  on  the  sea  to  the  south.  There  they  remain  until 
sundown.  The  children  that' can  walk,  amuse  themselves  on  the  beach  or  on 
the  piazzas,  coming  in  only  for  meals,  or  for  the  one  or  two  hours'  rest  and 
instruction  which  those  of  the  school  or  kindergarten  age  receive,  and  which 
is  given  in  a  large,  well-ventilated  room.*  At  night  the  windows  of  the 
wards  are  wide  open,  even  through  the  winter,  being  closed  only  for  a  half 
hour  in  the  morning  and  evening  when  the  children  are  being  washed  and 
dressed.  The  temperature  in  the  wards  differs  but  little  from  that  out  of 
doors,  varying  in  the  winter  from  ten  to  forty  degrees  above  zero.  The 
children  are  clothed  in  flannel  and  wear  warm  hoods  and  mittens.  There 
has  not  been  a  day  during  the  four  years  when  they  have  not  been  out  of 
doors  for  at  least  a  part  of  the  twenty-four  hours.  We  have  learned  that 
it  is  as  important  in  bone  tuberculosis  as  in  pulmonary  tuberculosis  that  the 
patient  should  spend  his  entire  time  in  the  open  air,  and  also  that  it  is  in 
cold  weather  that  he  makes  the  greatest  gain. 

The  diet  is  nourishing  and  abundant.  The  following  is  an  average 
daily  bill  of  fare: 

Breakfast:  Farina,  with  milk,  two  helpings.  Toast  with  chicken  gravy. 
Bread  and  butter,  two  to  four,  or  even  five  slices.  One  or  two  glasses 
of  milk. 

Dinner:  Roast  beef;  mashed  potatoes;  fresh  string-beans;  bread  and 
butter,  two  or  three  slices;  sago  pudding;  milk,  one  to  two  glasses. 

Supper:  One  egg;  buttered  toast,  two  to  five  slices;  stewed  peaches, 
milk  as  at  breakfast.  In  addition  the  children  have  a  light  luncheon  of 
crackers  and  milk  at  ten  o'clock,  and  fruit  or  crackers  and  milk  at  three 
o'clock  in  the  afternoon. 

This  diet  table,  as  may  be  seen,  is  not  arranged  scientifically,  but  is 
prepared  by  our  superintendent,  who,  in  addition  to  having  great  ability 
as  an  executive,  is  also  an  excellent  cook.  One  is  naturally  struck  with  the 
very  large  amount  of  food  the  children  eat,  and  yet  it  cannot  be  called  forced 

*  As  soon  as  it  had  been  decided  to  keep  the  children  through  the  winter,  steps 
were  taken  to  secure  a  teacher  from  the  Board  of  Education,  which  has  kindly  cooper- 
ated with  us  in  this  important  matter  and  has  supplied  not  only  teachers  but  also  a 
kindergartner.  Many  of  the  children  had  had  no  schooling  whatever  when  they  came 
to  the  hospital. 


SEA   BREEZE   HOSPITAL. — BRANNAN.  685 

feeding,  if  we  are  to  understand  by  this  term  food  that  is  forced  upon  the 
patients. 

A  rough  calculation  of  the  heat  values  of  the  food  consumed  in  one  day 
by  each  child  comes  to  about  2500  calories.  As  the  weight  of  the  children 
does  not  average  more  than  twenty  kilos,  this  gives  to  each  child  about  125 
calories  per  kilo — an  amount  greatly  in  excess  of  what  is  usually  given  in 
sanatoriums  to  patients  suffering  from  pulmonary  tuberculosis.  The  ability 
of  the  children  to  eat  and  digest  and  assimilate  so  much  food  is  probably 
due  to  their  living  in  the  open  air  throughout  the  twenty-four  hours.  The 
appetizing  manner  in  which  the  food  is  cooked  and  sei-ved  counts  for  much. 
It  is  probable  also  that  the  digestion  of  a  child  suffering  from  surgical  tuber- 
culosis is  not  so  easily  disturbed  as  that  of  a  person  suffering  from  pulmonary 
tuberculosis. 

I  have  spoken  of  the  rapid  progress  in  the  general  condition  of  the  chil- 
dren, as  shown  in  their  appearance,  their  circulation,  their  spirits,  their 
appetite,  their  sound  sleep,  and  their  gain  in  weight,  all  beginning  at  once 
with  their  coming  to  the  seashore.  The  improvement  in  the  local  lesions 
has  naturally  been  slower  in  manifesting  itself,  but  in  almost  all  cases  it  has 
appeared  in  a  surprisingly  short  space  of  time.  The  quick  and  permanent 
closing  of  sinuses  is  very  striking,  especially  under  the  direct  influence  of 
the  salt  water,  as  shown  in  the  following  instances: 

Mariano  A.,  thirteen  years  old,  was  admitted  in  June,  1904,  with  a  tuber- 
culous ankle-joint.  The  disease  began  in  1898,  and  there  was  a  history  of 
four  operations  in  Italy  and  one  in  New  York.  On  admission  there  were  two 
deep  sinuses,  one  over  each  malleolus,  with  considerable  discharge.  The 
boy,  though  quite  lame,  walked  about,  going  into  the  ocean  daily  and  coming 
out  with  the  wounds  packed  with  sand,  much  to  the  distress  of  the  nurses. 
Nevertheless  the  discharge  diminished  and  by  the  autumn  had  entirely 
ceased.  In  February,  1905,  both  sinuses  had  closed,  and  the  boy  was  ulti- 
mately discharged  with  the  joint  anchylosed  at  an  angle  of  95  degrees  and 
able  to  walk  and  play  with  no  noticeable  lameness. 

The  other  cases  were  among  the  children  who  had  daily  baths  during 
the  past  summer.  My  attention  was  called  to  them  by  Miss  Josephine  F. 
W.  Brass,  the  efficient  and  observing  head  nurse  of  the  hospital.  One  was  a 
case  of  hip  disease  with  two  sinuses,  one  of  disease  of  elbow  with  two  sinuses, 
and  one  of  disease  of  elbow  and  hand  with  three  sinuses.  They  went  into 
the  water  dressings  and  all,  the  wet  dressings  being  afterward  replaced  with 
dry  ones.  Under  this  treatment  all  of  the  sinuses  have  closed  completely 
since  the  first  of  July. 

It  is  not  my  intention  to  describe  in  detail  the  surgical  treatment  of  the 
children.  That  it  is  of  the  best  must  be  apparent  from  the  results.  Even 
residence  at  the  seaside  under  the  conditions  above  outlined  does  not  enable 


686  SIXTH   INTERNATIONAL   CONGRESS   ON  TUBERCULOSIS. 

US  to  dispense  with  skilful  orthopedic  care.  Serious  operations  are  rare, 
but  when  performed,  they  are  attended  with  less  depression  than  is  usual  in 
children.  In  fact  the  rapid  progress  after  operation  is  one  of  the  most 
characteristic  features  of  the  open-air  treatment  at  the  seashore.  Dr. 
Leonard  W.  Ely,  the  attending  surgeon,  and  Dr.  Brainerd  H.  Whitbeck,  his 
assistant,  have  been  prompt  in  recognizing  the  moment  for  a  change  in 
treatment,  and  have  replaced  the  brace  or  extension  frame  with  the  plaster 
jacket  or  the  spica,  so  as  to  get  the  patient  up  and  about  as  soon  as  possible. 

The  table  prepared  by  them  gives  in  detail  the  results  in  the  136  patients 
that  have  been  admitted  to  the  hospital  from  its  opening  down  to  the  31st 
of  July  of  this  year.  The  grave  character  of  the  cases  is  at  once  apparent 
from  the  table.  In  68  patients,  exactly  one-half,  the  spine  or  the  hip  was 
involved;  and  in  55  of  these,  or  81  per  cent.,  the  disease  was  in  an  advanced 
stage  at  the  time  of  admission  to  the  hospital.  The  significance  of  these 
figures  must  be  apparent  to  all,  for  Pott's  disease  of  the  spine,  and  tuber- 
culous disease  of  the  hip,  when  of  long  standing,  are  among  the  most  for- 
midable affections  that  the  surgeon  is  called  upon  to  meet.  In  seeking  to 
know  the  final  results  of  the  treatment,  we  are  obliged  to  limit  ourselves  to 
those  cases  whose  history  is  complete,  that  is,  the  discharged  cases.  The 
table  shows  that  of  the  19  patients  with  Pott's  disease,  26  per  cent,  were 
cured  and  another  32  per  cent,  improved,  making  58  per  cent,  that  were 
either  well  or  progressing  to  recovery  when  they  were  discharged.  Of  the 
23  cases  of  hip  disease,  all  of  them  advanced,  43  per  cent,  left  the  hospital 
absolutely  cured,  and  9  per  cent,  improved,  or  52  per  cent,  in  all  of  successes, 
as  the  French  term  it.  Orthopedic  surgeons  will  appreciate  the  significance 
of  these  results. 

Among  the  discharged  cases  there  were  22  in  which  the  knee  or  other 
joint  was  affected.  Over  81  per  cent,  of  these  were  in  an  advanced  stage,  and 
yet  an  average  of  73  per  cent,  were  cured,  and  13  per  cent,  more  improved, 
showing  the  relatively  good  prognosis  of  the  disease  when  located  in  these 
joints,  as  compared  with  tuberculosis  of  the  spine  or  hip.  Of  the  32  cases  of 
glandular  tuberculosis,  85  per  cent,  were  either  cured  or  improved,  a  very 
satisfactory  result.  As  stated  in  note  4  of  the  table,  in  13  patients  more 
than  one  part  of  the  body  was  involved.  Further  proof  of  the  average 
severity  of  the  tuberculous  process  in  the  cases  admitted  to  Sea  Breeze  is 
furnished  by  the  fact,  noted  in  the  complete  records  of  cases,  which  will  be 
found  at  the  end  of  this  pamphlet,  that  of  the  136  cases  65  had  one  or  more 
open  sinuses,  amounting  to  139  sinuses  in  all. 

On  July  31st  of  this  year,  there  remained  in  the  hospital  34  children,  and 
of  these  all  but  8  were  cases  of  spinal  or  hip  disease,  of  which  more  than  two- 
thirds  were  in  an  advanced  stage.*    The  surgeons,  however,  reported  that 

*  See  Note  2,  Table  I. 


SEA   BREEZE   HOSPITAL. — BRANNAN.  687 

all  were  improving  and  that  many  might  soon  be  discharged  cured.  Of  the 
34  cases,  21  were  confined  to  bed.  To-day  (October  1st),  three  months 
later,  only  14  are  in  bed,  7  having  been  fitted  with  plaster  jackets  and  sent  to 
join  the  other  children  at  play.  The  accompanying  photograph  shows  five 
of  these  children,  four  of  them  wearing  the  Calot  jacket,  which  Dr.  Ely  has 
found  of  such  great  service  during  the  past  year.  The  present  census  of 
the  hospital  is  39,  five  new  cases  having  been  admitted  since  July  31st,  only 
two  of  them  in  an  advanced  stage,  though  all  are  cases  of  undoubted  tuber- 
culosis of  the  bones  or  glands.  The  surgeons  state  that  it  is  the  present 
policy  of  the  hospital  to  accept  and  retain  only  such  cases  as  show  a  prospect 
of  being  cured. 

What  of  the  future  of  Sea  Breeze  Hospital?  It  is  well  understood  by 
its  friends  that  it  was  established  only  as  a  temporary  experimental  hospital 
to  test  the  seashore  and  open-air  treatment  of  non-pulmonary  tuberculosis 
in  children.  The  original  purpose  of  the  tent  camp  has  been  accomplished. 
It  has  been  demonstrated  that  to  obtain  the  best  results  in  the  treatment  of 
bone  and  gland  tuberculosis  it  is  essential  that  the  patient  should  spend  his 
entire  time  in  the  open  air.*  In  addition  it  has  been  shown  that  the  seashore 
offers  especial  advantages  for  outdoor  life  in  this  variety  of  tuberculosis. 
That  these  views  are  not  confined  to  those  immediately  connected  with  the 
hospital  is  proved  by  the  fact  that  subscriptions  to  the  amount  of  $250,000 
have  been  received  by  the  New  York  Association  for  Improving  the  Condition 
of  the  Poor  for  the  erection  of  a  permanent  hospital,  and  by  the  additional 
fact  that  the  city  has  agreed  to  provide  a  site  at  the  seashore  for  the  erection 
of  the  hospital  and  to  accept  and  maintain  it  when  completed.  In  March, 
1907,  after  prolonged  consideration  and  the  holding  of  a  largely  attended 
public  hearing  on  the  subject,  the  Board  of  Estimate  and  Apportionment 
resolved  by  a  unanimous  vote  to  purchase  Rockaway  Beach  for  the  purposes 
of  public  health  and  recreation.  A  portion  of  the  beach,  to  be  selected  by 
the  Association,  was  to  be  set  aside  as  a  site  for  the  hospital.  Condemnation 
proceedings  for  the  acquisition  of  the  property  were  duly  authorized,  and 
instituted  during  the  summer.  But  in  the  autumn  came  the  stringency 
in  the  money  market,  and,  in  common  with  other  measures  of  importance  to 
the  welfare  and  development  of  the  city,  the  proceedings  were  arrested  by 
those  responsible  for  its  financial  credit.  This  delay,  though  much  to  be 
deplored,  is,  we  believe,  only  temporary,  as  we  have  full  confidence  that  at 
the  earliest  possible  opportunity  the  municipal  authorities  will  redeem  their 
pledge  to  the  Association  and  to  the  4000  crippled  children  of  New  York 
city. 

*  "It  is  a  great  mistake  to  keep  children  with  bone  tuberculosis  in  the  wards  of  a 
city  hospital.  We  have  learned  that  the  ward  is  not  the  place  for  pulmonary  tubercu- 
losis, no  more  is  it  the  place  for  bone  tuberculosis." — Dr.  John  H.  Lowman,  Trans- 
actions of  the  National  Association  for  the  Study  and  Prevention  of  Tuberculosis, 
volume  ii,  May,  1906,  page  636. 


688 


SIXTH    INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 


TABLE  I.— SEA  BREEZE  HOSPITAL.     SUMMARY  OF  CASES  JUNE,  1904   TO 

JULY  31,  1908. 
Discharged  Cases. 


6 

Cured. 

Improved 

Unimp'ed. 

Died  in 
Hospital. 

CaSE8. 

d 

6 

6 

6 
^2; 

Spine 

Early 

5 

14 

19 

19 

1 
4 

5 

26 

2 
4 

6 

32 

2 
5 

7 

37 

1 
1 

Advanced 

Total 

5 

Hip 

Early 

22 

io 

10 

43 

2 
2 

9 

'8 
8 

35 

3 
3 

Advanced 

23 
23 

Total 

13 

Knee 

Early 

3 
6 

9 

9 

3 
4 

7 

80 

i 

1 

10 

"i 
1 

10 

Advanced 

Total 

Other  Joint 

Early 

1 
12 

13 

13 

1 

8 

9 

70 

2 

2 

15 

2 
2 

15 

Advanced 

Total 

Gland 

Early 

9 

24 

33 

32 

4 
10 

14 

42 

5 
9 

14 

43 

5 
5 

15 

Advanced 

Total 

Syphilis 

Early 

1 

4 

5 

5 

1 
3 

4 

80 

i 

1 

20 

Advanced 

Total 

Grand  Totals 

102 

49 

48 

26 

26 

23 

22 

4 

4 

Note  1. — Of  the  23  unimproved  cases  18  have  died  since  discharge,  from  various 
complications,  among  which  may  be  mentioned: 

Amyloid  degeneration  of  viscera 6 

Pulmonary  tuberculosis 4 

Hypostatic  pneumonia 2 

Meningitis 1 

Nephritis 1 

Multiple  sarcoma 1 

Causes  unknown 3 


Total. 


18 


■ 

Lp 

^!^^ 

1 

■ 

■ 

p 

^ 

P4 

1 

L 

. .                          y 

e!HffiF<W| 

■1 

SEA   BREEZE   HOSPITAL. — BR  ANN  AN.  689 

Note  2. — In  addition  to  the  102  discharged  cases  there  were  in  the  Hospital  on 
July  31,  1908,  34  cases  as  follows: 

Early.  Advanced.  Total. 

Spine 5  10  15 

Hip 3  8  11 

Knee 1  3  4 

Other  joint 1  1 

Gland 1  2  3 

Total 10  24  34 

These  34  cases  are  all  improving  and  many  may  soon  be  discharged,  cured.  At 
the  outset  the  Hospital  admitted  many  far  advanced  ca-ses  even  when  the  prognosis 
was  hopeless.  The  present  policy  of  the  Hospital  is  to  accept  only  such  cases  as  show 
a  prospect  of  being  cured. 

Note  3. — The  above  102  cases  had  many  complications,  among  which  were  the 
following: 

Syphilis 10 

Pulmonary  tuberculosis 6 

Amyloid  degeneration  of  viscera 6 

Diphtheria 3 

Hypostatic  pneumonia 2 

Otitis 2 

Nephritis 1 

Keratitis 1 

Multiple  sarcoma 1 

Hodgkin's  disease 1 

Total 33 

Note  4. — More  than  one  part  tuberculosis: 

Spine,  knee 1 

Spine,  gland 2 

Spine,  hip 

Spine,  jaw,  elbow 

Spine,  jaw 

Spine,  elbow 

Hip  ankle 

Hip,  elbow ; 

Knee,  elbow 

Rib,  finger 

Finger,  gland 

Orbit,  rib,  gland 

Total 13 

Note  5. — Tuberculous  ancestry: 

Father  and  mother  both  died 1 

Father  died 4 

Father  ill 11 

Mother  died 4 

Mother  ill ..... 2 

Other  relatives  ill 7 

Total 29 


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700 


SEA   BREEZE   HOSPITAL. — BRANNAN.  701 

Le  Traitement  k  I'Air  de  la  Mer  et  a  I'Air  pur,  employe  a  I'Hopital  "Sea 

Breeze,"  pour  les  Cas  de  Tuberculose  des  Os,  des  Articulations 

et  des  Glandes  chez  les  Enfants. — (Brannan.) 

L'hopital  "Sea  Breeze,"  le  premier  etablissement  experimental  americain 
pour  le  traitement  par  Fair  de  la  mer  de  la  tuberculose  des  os  et  des  glandes, 
fut  etabli  il  y  a  quatre  ans  sur  la  plage  de  Coney  Island,  par  la  New  York 
Association  for  Improving  the  Condition  of  the  Poor.  Les  enfants  pendant 
le  premier  ete  furent  loges  dans  des  tentes,  mais  depuis,  dans  un  batiment 
muni  de  nombreuses  fenetres  et  de  larges  balcons  ouverts.  On  y  regoit 
toutes  les  varietes  de  tuberculose  des  os,  des  articulations  et  des  glandes. 
On  n'a  pas  essaye  de  choisir  les  cas.  Quatre  cinquiemes  des  cas  sont  avances. 
Des  premiers  43  malades,  27  avait  un  ou  plusieurs  sinus  avec  ecoulement 
de  pus,  71  cas  en  tout.  Les  cas  qui  se  presenterent  ensuite  avaient  le  meme 
degrd  de  gravite.  Les  enfants  passent  24  heurs  en  plein  air,  le  jour  sur  la 
plage  ou  sur  des  v^randes  ouvertes,  la  nuit  dans  des  salles  dont  les  fenetres 
sont  ouvertes  de  tons  les  cotes  k  toute  saison  de  I'ann^e.  La  nourriture 
est  riche  et  abondante,  cinq  repas  par  jour,  bien  cuits  et  bien  servis.  Une 
amelioration  sensible  apparait  de  suite  chez  les  malades,  d'abord  dans  la 
condition  generale,  plus  tard  dans  les  lesions  locales.  L'amelioration 
generale  se  manifeste  dans  I'apparence,  la  vivacite,  I'appetit,  profond  som- 
meil  et  gain  de  poids.  Les  sinus  se  ferment  rapidement  et  d'une  maniere 
permanente,  surtous  s'ils  sont  exposes  directement  a  I'eau  de  mer;  tres-peu 
d'operations  necessaires,  mais  I'op^ration  est  suivie  d'un  progres  rapide, 
caracteristique  du  traitement  en  plein  air. 

Pendant  les  quatre  ans  136  malades  ont  ^t^  en  traitement;  68  de  ces 
malades,  la  moiti6  exactement,  etaient  des  cas  de  maladies  de  I'^pine  dorsale 
ou  de  la  hanche,  et  dans  81  pour  cent  ces  dernieres  affections  etaient  dans  un 
etat  avance  au  moment  de  I'admission  a  l'hopital.  Quarante-deux  des 
68  cas  ont  ^te  congedies,  et  36  pour  cent  de  ces  cas  congedies  etaient  gueris 
et  19  pour  cent  ameliorcs,  ce  qui  fait  un  total  de  55  pour  cent  qui  dtaient 
ou  gueris  ou  sur  le  chemin  de  la  guerison  quand  ils  quitterent  l'hopital. 
Parmi  les  cas  congedies,  il  y  en  avait  22  chez  lesquels  le  genou  ou  une  autre 
articulation  etait  affectee.  Quoique  80  pour  cent  fussent  dans  un  6tat 
avance,  73  pour  cent  furent  gueris  et  13  pour  cent  am^liores. 

L'avenir  de  l'hopital  Sea  Breeze.  Le  but  premier  est  atteint.  II  est 
d^montrd  que  pour  obtenir  les  meilleurs  r6sultats  dans  la  tuberculose  des 
OS  et  des  glandes,  le  malade  doit  passer  tout  son  temps  en  plein  air,  et  que 
le  bord  de  la  mer  offre  des  avantages  sp^ciaux  pour  la  vie  en  plein  air  pour 
les  enfants.  On  a  regu  des  souscriptions  d'on  total  de  S250,000  pour  un 
hopital  permanent.  La  ville  de  New  York  a  promis  un  emplacement 
pour  I'hdpital  et  s'engage  k  le  maintenir  quand  il  sera  fini. 


702  SIXTH   INTERNATIONAL  CONGRESS   ON  TUBERCULOSIS. 

Die  Behandlung  am  Meeresufer  und  in  der  freien  Luft  in  dem  Sea  Breeze 

Hospital  fiir  tuberkulose  Krankheiten  der  Knochen,  Gelenke 

und  Driisen. — (Brannan.) 

Das  Sea  Breeze  Hospital,  die  erste  amerikanische  Versuchsstation  fiir 
die  Seeluftbehandlung  fiir  Knochen-  und  Driisentuberkulose,  wurde  vor 
vier  Jahren  am  Strande  von  Coney  Island  von  der  New  York  Gesellschaft 
fiir  die  Verbesserung  der  Zustande  unter  den  Armen  (New  York  Association 
for  Improving  the  Condition  of  the  Poor)  errichtet.  Wahrend  des  ersten 
Sommers  wurden  die  Ivinder  in  Zelten  untergebracht,  seit  damals  jedoch 
in  Gebauden,  die  mit  zahlreichen  Fenstern  und  weiten,  offenen  Balkonen 
versehen  sind.  Alle  Arten  von  Knochen-,  Gelenk-  und  Driisentuberkulose 
werden  zugelassen.  Kein  Versuch  einer  Auswahl  wird  gemacht.  Vier 
Fiinftel  sind  vorgeschrittene  Falle.  Von  den  ersten  43  Patienten  hatten 
27  ein  oder  mehrere  eiterige  Fistelgange,  im  Ganzen  71  Fistelgange.  Derselbe 
Grad  von  schweren  Fallen  herrscht  auch  in  den  spateren  Patienten  vor. 
Die  Kinder  bleiben  die  ganzen  24  Stunden  in  der  freien  Luft,  am  Tage  am 
Ufer  oder  auf  den  offenen  Gallerien,  des  Nachts  in  Schlafsiilen,  deren  Fenster 
das  ganze  Jahi*  hindurch  weit  ojffen  sind.  Die  Diat  ist  nahrhaft  und  im 
Uberfluss  vorhanden,  fiinf  Mahlzeiten  taglich,  gut  gekocht  und  serviert. 
DeutUche  Besserung  ist  sofort  in  den  Patienten  ersichthch,  zuerst  im  All- 
gemeinzustande,  spater  in  den  lokalen  Affektionen.  Allgemeine  Besserung 
zeigt  sich  im  Aussehen,  der  Stimmung,  im  Appetit,  gesunden  Schlafe  und 
fortdauernder  Schliessung  der  Fisteln,  besonders  wenn  unmittelbar  dem 
Seewasser  ausgesetzt.  Operationen  sind  selten  notwendig,  wenn  aber 
ausgefiihrt,  sind  sie  von  raschem  Fortschritt  begleitet,  was  der  Freiluftbe- 
handlung  charakteristisch  ist. 

Wahrend  der  4  Jahre  waren  136  Patienten  in  Behandlung,  von  denen 
68,  genau  die  Halfte,  Falle  von  Riickgrat-  und  Hiift-ICrankheiten  waren. 
Von  diesen  waren  81%  in  einem  vorgeschrittenen  Stadium  zur  Zeit  ihrer 
Zulassung.  Zweiundvierzig  von  den  68  Fallen  sind  entlassen,  und  von 
diesen  sind  36%  geheilt  und  19%  gebessert,  im  Ganzen  55%,  die  entweder 
gesund  waren  oder  ihrer  Heilung  entgegenschritten,  als  sie  das  Spital  ver- 
liessen.  Unter  den  Entlassenen  waren  22,  in  denen  entweder  das  Knie 
oder  ein  anderes  Gelenk  ergriffen  war.  Obschon  80%  in  einem  vorgeschrit- 
tenen Stadium  waren,  wurden  doch  73%  geheilt  und  13%  gebessert. 

Der  urspriingUche  Zweck  erfiillt.  Es  ist  bewiesen,  dass,  um  die  besten 
Erfolge  zu  erlangen,  der  Patient  die  ganze  Zeit  in  der  freien  Luft  zubringen 
muss,  und  dass  das  Meeresufer  besondere  Vorteile  fiir  das  Leben  in  der 
freien  Luft  fiir  Kinder  darbietet.  Subscriptionen  im  Betrag  von  $250,000 
fiir  ein  permanentes  Spital  erhalten.  Die  Stadt  New  York  hat  einen  Platz 
fiir  das  Hospital  und  seine  Aufrechterhaltung  versprochen,  sobald  es  voUen- 
det  ist. 


THE  POSSIBILITY  OF  AVOIDING  CONSPICUOUS  SCAR 

FORMATION  IN  SOFTENED  TUBERCULOSIS 

OF   THE   CERVICAL   GLANDS. 

By  Willy  Meyer,  M.D., 

Professor  of  Surgery  at  the  New  York  Postgraduate  Medical  School  and  Hospital,  New  York. 


Every  surgeon,  when  confronted  with  the  necessity  of  operating  for 
broken-down  tubercular  glands  of  the  neck,  has  pondered  how  best  to 
proceed  in  order  to  cause  the  least  possible  scar  formation.  In  boys  and 
men  the  matter  is  not  important,  and  we  rarely  hesitate  to  advise  radical 
operation,  especially  if  saving  time  is  a  consideration.  It  is  different, 
however,  with  the  opposite  sex.  Here  the  surgeon  will  welcome  any  means 
that  may  tend  to  improve  the  cosmetic  result. 

If  we  make  the  skin  incision — even  if  it  be  inches  in  length — within  the 
normal  folds  of  the  neck,  transversely,  the  result  is  far  superior  to  that  ob- 
tained from  incisions  made  parallel  with  the  borders  of  the  sternocleido- 
mastoid muscle.  Still,  there  will  be  a  more  or  less  conspicuous  permanent 
mark.  Hence,  a  method  that  reduces  such  scar  formation  to  a  minimum, 
requiring  incisions  only  one-fifth  to  one-tenth  as  long  as  before,  should  be 
greeted  with  enthusiasm.  The  greater  time  and  trouble  such  a  procedure 
may,  in  these  cases,  call  forth  from  the  surgeon  and  his  attentions,  should 
not  deter,  when  the  result  is  taken  into  consideration.  The  treatment 
alluded  to  is  Bier's  artificial  h^'peremia.  The  personal  material  I  am  able 
to  offer  in  this  connection  is  rather  small.  The  hospital  with  wliich  I  am 
principally  associated  does  not  possess  a  large  children's  ward.  The  few 
beds  are  designed  for  emergency  cases  rather  than  chronic  cases.  The  pa- 
tients are  dispensary  cases,  rather  than  hospital  cases,  or  patients  that 
should  be  treated  in  the  surgical  division  of  country  sanatoriums.  Three  of 
my  patients  have  been  observed  in  dispensary  and  office  practice.  After 
some  improvement  at  the  end  of  a  few  weeks,  I  lost  sight  of  them,  so  that 
I  cannot  report  final  results.  In  all  five  patients  I  have  observed  the  same 
satisfactory  course  as  has  been  reported  by  others. 

I  made  these  patients  wear  the  elastic  neck-band  ten  hours  out  of  every 
twelve.  The  band,  made  of  the  same  material  as  the  black  elastic  rubber 
bandage,  with  a  button  in  one  end  and  a  number  of  buttonholes  in  the  other, 
is  a  very  comfortable  appliance.    The  one  made  of  the  ordinary  garter 

703 


704  SIXTH   INTERNATIONAL   CONGRESS   ON   TUBERCULOSIS. 

elastic,  with  a  hook  and  several  eyes,  comes  next.  The  compression  of  the 
deep  jugular  veins  should  not  be  sufficient  to  cause  the  patient  annoyance: 
he  must  be  able  to  talk,  eat,  drink,  breathe,  and  sleep  without  discomfort. 
In  fact,  he  must  hardly  be  aware  of  the  presence  of  the  band.  It  is  astonish- 
ing how  quickly  cliildren,  even  babies,  get  used  to  the  band. 

The  appearance  of  fluctuation  at  the  site  of  the  trouble  is  carefully 
watched  for.  It  may  be  hastened  by  the  continuous  application  of  a  warm 
wet  gauze  (Priessnitz)  dressing.  As  soon  as  it  appears,  a  short  cut  is  made, 
in  the  course  of  the  neck  fold,  and  the  pus  is  evacuated.  If  the  muscles 
or  subcutaneous  fat  tend  to  overlap  the  incision,  a  drain  of  small  size  is 
introduced  for  twenty-four  to  thirty  hours.  Otherwise,  the  wound  is  simply 
left  open  and  suction  treatment  started  four  to  five  hours  later. 

It  is  advisable  to  use  the  cup  once  daily  for  a  period  of  forty-five  minutes 
(i.  e.,  five  or  six  minutes  of  suction  with  two  or  three  minutes'  intermission 
each  time)  soon  after  the  bandage  has  been  removed.  Packing  or  injec- 
tions of  iodoform  emulsion  or  bismuth  paste  are  never  used.  It  will  be 
observed  that  glandular  debris  is  aspirated  with  the  pus.  It  is  natural  to 
place  both  the  fistulous  tract  and  the  entire  diseased  area  under  suction, 
thus  combining  the  hyperemic  effect  on  the  deeper  tuberculous  tissue  with 
regular  gentle  evacuation  of  the  abscess.  If  the  treatment  is  properly  car- 
ried out,  a  mixed  infection  will  not  occur.  Soon  the  purulent  secretion 
becomes  serous.  In  favorable  cases  the  opening  closes  rapidly.  The  remain- 
ing slight  infiltration  gradually  becomes  absorbed  under  the  continued  use  of 
the  elastic  neck-band. 

It  stands  to  reason  that  a  patient  in  whom  a  sinus  has  already  developed, 
when  first  seen  can  be  equally  successfully  treated  by  this  method,  but  the 
elastic  band  should  always  assist  the  suction  treatment. 

Bier  himself  seems  to  be  satisfied  with  suction  treatment  alone.  From 
what  I  have  seen,  however,  I  believe  it  worth  while  to  use  the  remaining 
twenty  to  twenty-two  hours,  trying  to  influence  the  tuberculous  tissue  by 
hyperemia  produced  with  the  neck-band.  Klapp,  among  others,  has 
reported  a  most  striking  case  of  tliis  kind.* 

With  the  permission  of  a  colleague  I  relate  the  following  case: 

Boy,  five  years  of  age,  the  only  surviving  child  of  a  number  of  children, 
developed  a  package  of  tuberculous  glands  in  front  of  the  sternocleido 
muscle,  right  behind  the  angle  of  the  jaw,  following  some  throat  trouble. 
His  parents,  on  account  of  the  delicate  condition  of  the  boy,  live  in  the  coun- 
try all  the  3^ear  around.  They  are  as  greatly  averse  to  placing  the  child  in 
a  hospital  as  they  are  to  radical  extirpation,  since  they  have  only  recently 
lost  another  child  soon  after  an  operation.  The  glands  are  softened;  deep 
fluctuation  can  be  made  out.     The  family  physician  is  familiar  with  hyper- 

*  A.  Bier,  on  Hyperemia,  p.  219,  P.  4. 


AVOIDING   SCAR   FORMATION. — MEYER.  705 

emic  treatment,  favors  its  use  in  this  case,  and  asks  my  advice.  The  case 
seemed  especially  adapted  for  this  procedure.  Consequently  an  elastic 
neck-band  and  a  set  of  properly  fitting  cups  were  procured  and  a  trained 
nurse  was  engaged.  The  band  did  not  give  the  slightest  annoyance.  The 
boy  seemed  perfectly  at  ease,  riding  his  bicycle  and  playing  around  to  his 
heart's  content.  Under  ethyl  chlorid  spray  and  local  cocain  anesthesia  the 
abscess  was  opened  by  a  short  transverse  incision  in  the  course  of  the  neck 
fold,  and  suction  treatment  started.  In  this  way,  with  the  little  patient 
in  his  former  surroundings,  all  day  long  in  the  fresh  air,  with  milk  feeding  from 
their  own  cow,  the  trouble  took  a  more  favorable  course.  The  wound  closed 
definitely  four  weeks  after  incision.  All  the  glandular  enlargement  gradually 
disappeared. 

To-day,  four  months  later,  a  minute  scar,  about  three-quarters  of  an 
mch  long,  well  hidden  in  the  natural  fold  of  the  neck,  is  the  only  remaining 
sign  of  the  previous  existence  of  a  tuberculous  gland. 

Of  course,  the  method  will  not  succeed  in  every  case ;  artificial  hyperemia 
is  no  panacea.  In  the  more  serious  cases,  e.  g.,  multiple  softened  glandular 
tuberculosis  of  the  neck,  general  antituberculous  treatment  with  tuber- 
culin injections  may  be  advantageously  added. 

The  lung  suction  mask,  too,  may  well  be  put  into  service  in  these  cases. 
For  it  has  been  proved  that  it  not  only  produces  hyperemia  of  the  lung  tissue 
by  suction,  but  constitutes  one  of  our  best  means  of  improving  the  condition 
of  the  blood  in  all  its  components.  It  deserves  a  much  wider  use  than  it 
has  been  hitherto  accorded.  If  the  present  device  does  not  fully  answer 
all  the  requirements,  something  better  will  be  constructed.  The  principle, 
certainly,  is  correct,  and  should  be  used  in  our  fight  against  pulmonary  as  well 
as  other  tuberculous  diseases.  It  is  unfortunate  that  Kuhn's  mask  is  pro- 
tected by  patents  which  render  it  costly  of  importation  and  difficult  of 
repair. 

In  conclusion  I  would  say  that  my  personal  results  from  the  combined  use 
of  the  elastic  neck-band  and  the  suction  cups  have  been  brilliant  and  rapid 
also,  in  cases  of  broken-dowm  cervical  adenitis  following  tonsillitis  (e.  g.,  of 
scarlet  fever),  or  following  suppurative  periostitis  of  the  jaw  and  other  causes. 

But  no  matter  what  the  etiology,  I  am  convinced  that  the  treatment 
above  outlined  merits  the  full  and  most  careful  attention  of  every  physician 
and  surgeon,  and  is  of  particular  value  in  female  patients.  The  well-known 
chains  of  hard  tumors,  in  smaller  or  larger  packages,  belonging  to  the  type  of 
glandular  tuberculosis  of  the  neck,  are  distinctly  operative  cases. 


VOL.  11—23 


Index  to  Volume  II,  Section  III. 


Abdominal  Tuberculosis,  Acute  Forms 
of.— Dr.  D.  N.  Eisendrath 303 

*Air  frais  combing  avec  le  traitemeiit 
par  I'hyper^mie  dans  les  cas  chir- 
urgicaux  de  tuberculose  compliquee 
des  OS  chez  les  adultes, — Du  traite- 
ment  par  I'. — Dr.  W.  Meyer 217 

*Aire  Puro  Combinado  con  el  Trata- 
miento  Hiper^mico  en  los  Casos 
Quirurgicos  de  Tuberculosis  de  los 
Huesos  en  el  Adulto. — Dr.  W. 
Meyer 217 

*Augenh6hle,  Werth  der  Ophthalmo- 
Tuberculin-Probe  in  der  chinirgi- 
schen  Behandlung. — Dr.  C.  A.  Oliver    28 

Beck,  Dr.  Carl.— The  Value  of  the 
Roentgen  Method  in  the  Early 
Recognition  of  Tuberculosis  of 
Bones  and  Joints 144 

Beck,  Dr.  E.  G.— The  Surgical  Treat- 
ment of  Tuberculous  Sinuses  and 

their  Prevention 219 

Discussions 59,  77, 124,  256, 310 

Bellamy,  Dr.  Russell 124 

Beriin,  Dr.  H 77 

Bevan,   Dr.   A.   D. — Tuberculosis  of 

the  Kidney 176 

Discussion 310 

*  Bladder,  Tuberculosis  of  the. — Dr. 
W.  Karo 162 

Bladder,  Tuberculosis  of  the. — Dr. 
B.  Lewis ■ 165 

Blake,  Dr.  C.  J. — Tubercular  Disease 
of  the  Middle  Ear 35 

Blasentuberkulose. — Dr.  W.  Karo.  .  .    157 

Bones  and  Joints,  Plow  the  State  of 
Minnesota  cares  for  its  Indigent 
Children  suffering  from  Tuberculo- 
sis of  the.— Dr.  A.  J.  Gillette 251 

Bones  and  Joints,  Tuberculosis  of 
the.— Dr.  E.  H.  Bradford 204 

*Bony  and  Articular  Cavities  with 
Mosetig  Paste,  Obliteration  of  Tu- 
berculous.— Prof.  Nov^-Josserand .    142 

Bradford,   Dr.    E.    H. — Tuberculosis 

of  Bones  and  Joints 204 

Discussion 256 

Breast,  Tuberculosis  of  the. — Dr.  W. 
L.  Rodman 346 

Cabot,  Dr.  A.  T 124 


*Cadera,  Arthritis  Tuberculosa  de  la. 
—Dr.  S.  H.  Weeks 100 

Calot,  Prof.  F.— Treatment  of  Hip- 
joint  Disease 148 

Caravia,  Dr.  E 122,  256 

Casselberry,  Dr.  W.  E. — Tuberculo- 
sis of  the  Larynx 12 

*  Cervical-Lymphdriisen,  Tuberkulose 

der.  Bericht  fiber  275  Falle  von 
Radical-Extirpation. — Dr.  C.  N. 
Dowd 58 

Cervical  Lymph-nodes,  Tuberculosis 
of  the.  Report  of  275  Cases 
treated  by  Radical  Extirpation. — 
Dr.  C.N.  Dowd 54 

Chirurgicale,  La  cure  d'altitude  et  la 
cure  solaire  de  la  tuberculose. — Dr. 
RoUier 301 

*  Chirurgicaux  de  la  tuberculine,  As- 

pects.—Dr.  R.  W.  Phihp 203 

*Chirurgie,    liber    die    Stellung    des 

Tuberculins    in    der. — Dr.    R.    W. 

Phihp 203 

Chirurgische  Behandlung  der  Lungen- 

Tuberkulose,  die. — Prof.  S.  Sauer- 

bruch 82 

Codivilla,  Dr.  D.  A. — Immobilization 

in  Tuberculous  Arthritis 129 

ConneU,  Dr.  G 310 

Construction  of  Hospitals  for  Tuber- 
culosis Patients. — Mr.  M.  J.  Sturm  5 
*C6rnea,    Tuberculosis    de    la. — Dr. 

Oscar  Dodd 33 

*Cornea,  Tuberkulose  der. — Dr.  Oscar 

Dodd 34 

Cornea,    Tuberculosis    of    the. — Dr. 

Oscar  Dodd 29 

*Corn^e,     Tuberculose    de     la. — Dr. 

Oscar  Dodd 33 

Corwin,  Dr.  R.  W 207 

Cuguill6re,  Dr 123 

Cuvelier,  Dr 123 


Dodd,    Dr.    Oscar. — Tuberculosis    of 

the  Cornea 29 

Dowd,  Dr.  C.  N. — Tuberculosis  of  the 
Cervical  Lymph-nodes:  Re- 
port   on    275   Cases    treated   by 

Radical  Extirpation 54 

Discussions 60, 72 


*  Abstract. 
707 


708 


INDEX   TO   VOLUME    II,    SECTION   III. 


PAGE 

Ear,  Tubercular  Disease  of  the. — 
Dr.  C.  J.  Blake 35 

Eisendrath,  Dr.  D. — The  Acute  Forms 
of  Abdominal  Tuberculosis 303 

Esmonet,  Dr.  C. — A  Study  of  Experi- 
mental Tuberculosis  of  the  Testi- 
cle    323 

Finney,  Dr.  J.  M.  T 267 

Frauenthal,    Dr.    H.    W. — Rational 

Spinal  Support 311 

Discussion 256 

*Frische  Luft,  combinirt  mit  Hyperii- 
mie,  angewandt  in  der  Behand- 
lung  complizirter  Fillle  von 
Knochentuberkulose  bei  Erwachs- 
enen.— Dr.  W.  Meyer 218 

GaUagher,  Dr.  F.  W 11 

Generative  Organs,  Tuberculosis  of 
the  Female.— Dr.  I.  S.  Stone 188 

Genou,  Deux  formes  particulieres 
d'arthropathies  tuberculeuses  du. — 
Dr.  Mauclaire 126 

Gillette,  Dr.  A.  J.— How  the  State 
of  Minnesota  cares  for  its  Indigent 
Children  suffering  from  Tubercu- 
losis of  the  Bones  and  Joints 251 

*Hanche,  Arthrite  tuberculeuse  de  la. 
—Dr.  S.  H.  Weeks 109 

Hartmann,  Dr.  H. — Surgical  Forms 
of  Intestinal  Tuberculosis 183 

Hip  Disease  by  Weight  Bearing  and 
Fixation  by  the  Lorenz  Short  Hip 
Spica,  The  Treatment  of  Tubercu- 
lous.—Dr.  H.  A.  Wilson Ill 

Hip-joint,  Tubercular  Arthritis  of  the 
—Dr.  S.  H.  Weeks 100 

Hip-joint  Disease,  Treatment  of. — 
Prof.  F.  Calot 148 

Hotchkiss,  Dr.  L.  W. — Tuberculosis 
of  the  Stomach,  Liver,  Gall-blad- 
der, and  Pancreas 289 

*  Huesos  y  de  las  Articulaciones,  Como 

el  Estado  de  Minnesota  Cuida  por 
los  Ninos  Indigentes  Afectados  de 
Tuberculosis  de  los. — Dr.  A.  J. 
Gillette 255 

*  Huesos  y  de  la  Tuberculosis  Articu- 

lar, Obliteracion  de  las  Cavidades 
delos,  por  Medio  de  la  Pasta  de 
Mosetig. — Dr.  Nov6-Josserand .  .  .  .  142 
♦Hiiftenerkrankungen  mit  Lasten- 
tragen,  und  Fixation  mit  Lorenz'- 
scher  Hiiften-Spica,  die  Behand- 
lung  von  tuberculosen. — Dr.  H.  A. 
Wilson 116 


PAGE 

*Huftgelenks,    tuberculose    Arthritis 

des.— Dr.  S.  H.  Weeks 109 

Hunner,  Dr.  Guy  L 172 

Illyes,  Dr.  G.  von. — Uber  die  Nieren- 
tuberkulose 315, 1 

*  Immobilisation  dans  I'arthrite  tuber- 
culeuse. Importance  de  1'. — Dr.  A. 
Codivilla 137 

Immobilization  in  Tuberculous  Arth- 
ritis.—Dr.  A.  Codivilla 129 

*Immovilizacion  en  la  Artritis  Tuber- 
culosa, Importoncia  de  la. — Dr. 
A.  Codivilla 135 

Intestinal  Tuberculosis,    Surgical 

Forms  of. — Dr.  H.  Hartmann 183 


Josserand,  Dr.  Nov^. — De  I'oblit^ra- 
tion  des  cavit^s  osseuses  et  articu- 
laires  tuberculeuses  avec  la  pdte 
de  Mosetig 1, 140 

Karo   Dr.  Wilhelm 1 

Blasentuberkulose 157 

Discussion 175 

*Kehlkopfes,  Tuberculose  des:  die 
der  Heilung  zugiingliche  Form  der- 
selben  und  deren  Behandlungs- 
Prinzipien. — Dr.  W.  E.  Cassel- 
berry 24 

Kidney,  Tuberculosis  of  the. — Dr. 
A.  D.  Bevan 176 

*Kidney,  Tuberculosis  of  the. — Dr.  B. 
von  Rihmer 321 

*'Kidneys,  Tuberculosis  of  the. — Dr. 
G.  von  Illyes 315 

*Knee,  Two  special  Forms  of  Tu- 
berculous Arthropathy  of  the. — 
Dr.  Mauclaire 128 

*Kniees,  zwei  besondere  Formenvon 
tuberkuloser  Arthropathie  des. — 
Dr.  Mauclaire 127 

*Knochen-  \md  Gelenkshohlen  durch 
die  Mosetig  Paste,  Obliteration 
von  tuberkulosen. — Dr.  Nov6-Jos- 
serand 142 

Korsell,  Dr 175 

Kyle,  Dr.  D.  B.— The  Surgical  Treat- 
ment of  Tubercular  Lesions  of  the 
Upper  Respiratory  Tract 40 


*Laringe,  Tuberculosis  de  la:    Casos 

Capaces    de    Recuperar. — Dr.    W. 

E.  Casselberry 23 

*  Larynx,  Tuberculose  du:  le  Type 

Susceptible  de  Gu^rison. — Dr.  W. 

E.  Casselberry 24 


INDEX   TO   VOLUME   II,    SECTION   III. 


709 


PAGE 

Larynx,  Tuberculosis  of  the:  The 
Type  which  is  Capable  of  Recovery 
and  the  Principles  of  Treatment. — 
Dr.  W.  E.  Casselberry 12 

Lesions  of  the  Upper  Respiratory 
Tract,  The  Surgical  Treatment  of 
Tubercular. — Dr.  D.  B.  Kyle 40 

Lewis,  Dr.   Bransford. — Tuberculosis 

of  the  Bladder 165 

Discussion 175 

Lindahl,  Dr.  John 110 

*Linfaticos  Cervicales,  Tuberculosis 
de  los  Nudos.  Relato  de  275 
Casos  Tratados  por  Medio  de  la 
Extripacion  Radical. — Dr.  C.  N. 
Dowd 58 

Lower,  Dr.  W.  E 175 

Lund,  Dr.  F.  C. — Tuberculosis  of  the 
Peritoneum 189 

Lung  and  Pleura,  Surgical  Aspects 
of  Tuberculosis  of  the. — Dr.  S. 
Robinson 73 

*Lungen  und  der  Pleura,  die  Aussich- 
ten  fiir  chirurgische  Behandlung 
der  Tuberkulose  der. — Dr.  S.  Rob- 
inson      80 

*Lymphatiques  cervicales,  Tubercu- 
lose  des  glandes.  Histoire  de  275 
cas  traites  par  extripation  radicale. 
—Dr.  C.  N.  Dowd 58 


Mauclaire,  Dr. — Deux  formes  parti- 
culieres  d'arthropathies  tubercu- 
leuses  du  genou 126 

Mayo,  Dr.  C.  H.,  President's  Address.       1 
Discussion 59 

Meyer,  Dr.  W. — Open-air  and  Hy- 
peremic  Treatment  as  Powerful 
Aids  in  the  Management  of 
Complicated  Surgical  Tuberculo- 
sis in  Adults .- 212 

Discussions 110,174,  256 

Mitchell,  Dr.  J.  F. — Tuberculosis  of 
Muscles,  Tendons,  and  Fascia 279 

Mosher,  Dr.  H.  P. — Tuberculosis  of 
the  Nose,  Mouth,  and  Phaiynx ...     43 

Muscles,  Tendons,  and  Fascia,  Tuber- 
culosis of  the.— Dr.  J.  F.  Mitchell.  .    279 

*  Muscles,  Tendons  et  Fascies,  Tu- 
berculosc  des.— Dr.  J.  F.  Mitchell.  .   288 

*Muskeln,  Sehnen,  und  Fascien,  Tu- 
berkulose der.— Dr.  J.  F.  Mitchell  .   288 


*Nierentuberkulose,  die  Behandlung 
der.— Dr.  T.  Rovsing 278 

Nierentuberkulose,  iiber. — Dr.  B. 
von  Rihmer 318 

Nierentuberkulose,  tiber  die. — Dr.  G. 
von  Illyes 315 


Nierman,  Dr.  H.  G 310 

Nose,  Mouth,  and  Pharynx,  Tubercu- 
losis of  the.— Dr.  H.  P.  Mosher 43 


Ochsner,  Dr.  E.  H. — Vaccine  Therapy 

in  Joint  Tuberculosis 117 

Discussion 125 

*Ojo,  el  Tratamiento  Quirurgico  de 
las  Enfermedades  del — valor  de  la 
Prueba  Oftalmica  de  la  Tubercu- 
lina  en. — Dr.  C.  A.  Oliver 27 

Oliver,  Dr.  C.  A.— The  Ophthalmo- 
tuberculin  Test 26 

Open-air  and  Hyperemic  Treatment  as 
Pov.'erful  Aids  in  the  Management 
of  Complicated  Surgical  Tuberculo- 
sis in  Adults. — Dr.  W.  Meyer 212 

*Orbitaires,  le  traitement  chirurgical 
des  maladies.  La  Valeur  de  la 
r^actionophthalmo  -  tuberculine. — 
Dr.  C.  A.  Oliver 27 

Orbital  Disease,  A  Brief  Note  upon 
the  Value  of  the  Ophthalmic- 
tuberculin  Test  in  the  Question  of 
Surgical  Tuberculosis  of. — Dr.  C. 
A.  Ohver 26 

*Oreille,  La  tuberculose  de  1'. — Dr. 
C.  J.  Blake 39 

*Osseuse  et  articulaire,  Comment 
r^tat  de  Minnesota  prend  soin  des 
enfants  pauvres  atteints  de  tuber- 
culose.—Dr.  A.  J.  Gillette 255 

Osseuses  et  articulaires  tuberculeu- 
ses  avec  la  pate  de  Mosetig, 
De  I'obliteration  des  cavitfe. — Dr. 
Nove-Josserand 140 


Painter,  Dr.  C.  F. — Retroperitoneal 
Tuberculous  Glands  and  their 
Relation  to  Spinal  Symptoms.  ...     61 

Peritoneum,  Tuberculosis  of  the. — 
Dr.  F.  C.  Lund 189 

Philip,  Dr.  R.  W. — Surgical  Bearings 
of  Tuberculin 1, 199 

President's  Address. — Dr.  C.  H.  Mayo.       1 

*Pulmones  y  de  la  Pleura,  Los  Aspec- 
tos  Quirurgicos  de  la  Tuberculosis 
de  los. — Dr.  S.  Robinson 78 


*Quirurgica,  El  Tratameinto  al  aire 
Libre  de  la  Tuberculosis. — Dr.  De 
Forest  Willard 266 

♦Quirurgicos,  La  Tuberculina  en  los 
Casos.— Dr.  R.  W.  Philip 203 

*R(5nal,  Traitement  de  la  tuberculose. 
—Dr.  T.  Rovsing 277 


710 


INDEX  TO   VOLUME    II,    SECTION   III. 


PAGE 

♦Renal,  Tratamiento  de  la  Tubercu- 
losis.— Dr.  T.  Rovsing 277 

Retroperitoneal  Tuberculous  Glands 
and  their  Relation  to  the  Spinal 
Symptoms.— Dr.  C.  F.  Painter 61 

Rihmer,  Dr.  B.  von. — Uber  Nieren- 
tuberkulose 318 

*Ri nones,  Tuberculosis  de  los. — Dr. 
B.  von  Rihmer 322 

Robinson,  Dr.  S. — Surgical  Aspects 
of  Tuberculosis  of  Lung  and  Pleura.     73 

Rodman,  Dr.  Wm.  L. — Tuberculosis 
of  the  Breast 346 

Roentgen  Method  in  the  early  Recog- 
nition of  Tuberculosis  of  Bones  and 
Joints,  The  Value  of. — Dr.  Carl 
Beck 144 

*Rognons,  Tuberculosa  des. — Dr.  G. 
von  Illyes 316 

RoUier,  Dr. — La  cure  d'altitude  et  la 
cure  solaire  de  la  tuberculosa  chir- 
urgicale 301 

Rovsing,  Dr.  Thorkild. — Tuberculo- 
sis of  the  Urinary  Tract 268 

Sala,  Dr.  E.  M 59 

Sauerbruch,  Prof.- — Die  chirurgische 
Behandlung  der  Lungen-Tuberku- 
lose 82 

Schmidt,  Dr.  L.  E 174 

*Sinus  tuberculeux,  Traitement  chi- 
rurgical  des.— Dr.  E.  G.  Beck .    250 

Sinuses  and  their  Prevention,  Surgi- 
cal Treatment  of  Tuberculous. — 
Dr.  E.  G.  Beck 219 

Spinal  Support,  Rational. — Dr.  H. 
W.  Frauenthal 311 

Stomach,  Liver,  Gall-bladder,  and 
Pancreas,  Tuberculosis  of  the. — 
Dr.  L.  W.  Hotchkiss 289 

Stone,  Dr.  I.  S. — Tuberculosis  of  the 
Female  Generative  Organs 188 

Sturm,  Mr.  Meyer  J. — Construction 
of  Hospitals  for  Tuberculosis  Pa- 
tients         5 

Surgical  Bearings  of  Tuberculin. — Dr. 
R.  W.  Philip 199 

Surgical  Tuberculosis,  Outdoor  Treat- 
ment of  .—Dr.  DeForest  Willard ...   257 


PAGB 

Taylor,  Dr.  T 124 

Testicle,   A  Study  on  Experimental 

Tuberculosis     of     the.  —  Dr.     C. 

Esmonet 323 

Townsend,  Dr.  W.  R 72 

*Traitamiento  por  Medio  de  la  Carga 

de  Pesos  y  el  Fijamiento   al  Espi- 

gon  de  la  Cadera,  de  Lorenz. — Dr. 

H.  A.  Wilson 115 


*Unbe\veglichkeit  bei  tuberkuloser 
Arthritis,  die  Wichtigkeit  der. — ■ 
Dr.  D.  A.  Codivilla 138 

Urinary  Tract,  Tuberculosis  of. — Dr. 
T.  Rovsing 268 


*Vaccinale  dans  la  tuberculose  arti- 
culaire,  Therapie. — Dr.  E.  H.  Ochs- 
ner 121 

*Vaccine-Behandlung  bei  Gelenks- 
Tuberkulose.— Dr.  E.   H.  Ochsner  122 

Vaccine  Therapy  in  Joint  Tuberculo- 
sis.—Dr.  E.  H.  Ochsner 177 

*Vacuna-terapia  en  la  tuberculosis 
de  las  Articulaciones. — Dr.  E.  H. 
Ochsner 121 

Vas,  Epididymis,  and  Testicle,  Tuber- 
culosis of  the.— Dr.  J.  B.  Walker.  .    149 

*Vejiga,  Tuberculosis  de  la. — Dr.  W. 
Karo 163 

*Vessie,  Tuberculose  de  la. — Dr.  W. 
Karo 164 


Walker,  Dr.  J.  B. — Vas,  Epididymis, 

and  Testicle,  Tuberculosis  of  the.  .    149 
Weeks,  Dr.  S.  H.— Tubercular  Arth- 
ritis of  the  Hip-joint 100 

Whitbeck,  Dr.  B.  H 256 

Willard,  Dr.  DeForest. — Open-air 
Treatment  of  Surgical  Tuberculo- 
sis    257 

Discussions 124,  267 

Wilson,  Dr.   H.  A.— The  Treatment 
of  Tuberculous  Hip  Disease  by 
Weight    Bearing    and    Fixation 
by  the  Lorenz  Short  Hip  Spica .  .    Ill 
Discussion 125 


Index  to  Volume  II,  Section  IV. 


Abdominal  Tuberculosis  in  Great 
Britain  and  the  United  States, 
The  Relative  Frequency  of  in 
Children. — Dr.  David  Bovaird,  Jr.  . 

*Abdominal  tuberculosis,  La  fre- 
cuencia  de,  en  la  Gran  Bretana  y 
los  Estados  Unidos.— Dr.  David 
Bovaird,  Jr 

L'Air  confine  et  de  la  tuberculose, 
de.— M.  A.  Rey 

♦Albuminuria  of  Childhood,  Intermit- 
tent, Considered  in  its  Relation  to 
Hereditary  Tuberculosis. — Dr.  J. 
Teissier 

♦Albuminuric  in  der  Kindheit  in  ihren 
Beziehungen  zu  erblicher  Tuber- 
kulose  betrachtet,  intermittierende. 
— -Dr.  J.  Teissier 

Albuminuries  intermittentes  de  I'en- 
fance  considerees  dans  leurs  rela- 
tions avec  I'h^r^dite  tuberculeuse, 
Des. — Dr.  J.  Teissier 


Barnes,  Dr.  N.  P. — Hygiene  of  Mouth, 
Nares,  Pharynx,  Intestine,  Skin, 
Mucous  Membrane  in  General,  of 
Lymph  Bodies  and  Lungs;  Preven- 
tion of  Colds 

*Bauchtuberkulose  in  Grosebritannien 
und  den  Vereinigten  Staaten,  rela- 
tive Hiiufigkeit  von. — Dr.  David 
Bovaird,  Jr 

Baumel,  Dr.  A. — Ein  Resolutionsvor- 
schlag 

Bello,  Dr.  M.  J. — Higiene  Escolar  en 
el  Ecuador 

Bovaird,  Dr.  David,  Jr. — The  Rela- 
tive Frequency  of  Abdominal 
Tuberculosis  in  Children  in 
Great    Britain   and    the   United 

States 

Discussion 

Bowditch,  Dr.  H.  I.— A  Clinical  Study 
of  the  Transmission  and  Progress 
of  Tuberculosis  in  Children  Through 
Family  Association 

Bradstreet,  Mr.  H. — Relation  of  Tu- 
berculosis to  Parks  and  Play- 
grounds  


446 


453 
534 


477 


473 


671 


452 
603 


537 


446 
513 


493 


619 


PAGE 

Brannan,  Dr.  J.  W. — Seashore  and 
Fresh-air  Treatment  at  Sea  Breeze 
Hospital 682 

Breast-milk.  The  Opsonic  Content  of. 
—Dr.  W.  J.  Butler 390 

Butler,  Dr.  Wm.  J. — The  Opsonic 
Content  of  Breast-milk 390 


Calmette's  Ophthalmic  Reaction  to 
Tuberculin,  The  Value  and  Relia- 
bility of,  for  the  Diagnosis  of  Tu- 
berculosis and  Differentiation  of 
Tuberculous  Lesions  from  other 
Diseases  in  Infants  and  Young 
Children.— Dr.  E.  M.  Sill 542 

Carpenter,  Dr.  H.  C. — Tuberculous 
Pulmonary  Cavities  in  Infants.  . .  .   434 

Cavities,  Tuberculous  Pulmonary, 
in  Infants. — Drs.  C.  Y.  White  and 
H.  C.  Carpenter 434 

Chapin,  Dr.  H.  D. — Recent  Tests  in  the 
Diagnosis  of  Tuberculosis  in  Chil- 
dren at  the  New  York  Post-Gradate 
Medical  School  and  Hospital 575 

Children  of  the  Tuberculous. — Dr.  T. 
Sachs 479 

Children  of  Tuberculous  Parents, 
The  Occurrence  of  Pulmonary  Tu- 
berculosis in. — Dr.  J.  A.  Miller.  .  .  .   487 

Children,  Recent  Tests  in  the  Diagno- 
sis of  Tuberculosis  in,  at  the  New 
York  Post-Graduate  School  and 
Hospital.— Dr.  H.  D.  Chapin  and 
Dr.  T.  H.  Coffin 575 

Children's  Gardens  in  Congested 
Neighborhoods  for  those  Children 
with  a  Tendency  to  Tuberculosis, 
or  for  those  in  whom  the  Disease 
has  been  Arrested  or  Cured,  The 
Value  of.— Mrs.  H.  G.  Parsons 608 

Children,  Tuberculosis  in,  particu- 
larly with  Reference  to  Tubercu- 
losis of  the  Lymphatic  Glands  and 
its  Importance  in  the  Invasion  and 
Dissemination  of  the  Disease. — 
Dr.  T.  Shennan 367 

Clinical  Manifestations  of  Tubercu- 
lous Meningitis. — Dr.  D.  J.  Mc- 
Carthy and  Dr.  C.  A.  Fife 399 


♦Abstract. 
711 


712 


INDEX   TO   VOLUME    II,    SECTION   IV. 


Coffin,  Dr.  T.  H.— Recent  Tests  in  the 
Diagnosis  of  Tuberculosis  in  Chil- 
dieu  at  the  New  York  Post-Grad- 
uate  Medical  School  and  Hospital .    575 

Comby,  Dr.  J. — Role  de  la  contagion 
humaine  dans  la  tuberculosa  in- 
fantile    503 

Copeland,  Dr.  E.  P.— The  Relation 
of  Measles,  Whooping-cough  and 
Influenza  to  Tuberculosis  in  Child- 
hood    379 

Craig,  Dr.  F.  A. — The  Prognosis  in 
Pulmonary  Tuberculosis  in  Chil- 
dren under  Fifteen  years  of  age.  .  .  .   652 

Cronin,  Dr.  J.  J. — Obstructive  Ab- 
normalities of  the  Nose  and  Throat : 
Predisposing  Factors  to  Tubercu- 
losis in  School  Children 515 

Cutaneous  and  Ophthalmic  Tubercu- 
lin Tests  in  Infants  under  Twelve 
Months  of  Age.— Dr.  H.  L.  K. 
Shaw 547 


*Diagnose  der  Tuberkulose  im  Saug- 
lingsalter  und  in  der  Kindheit 
durch  die  Hautinoculation  von  Tu- 
berkulin. — Dr.  L.  Fischer 587 

Diagnosis  of  Tuberculosis  in  Infancy 
and  Childhood  by  means  of  the 
Inoculation  of  Diluted  Tuberculin 
or  Pure  Tubercuhn,  An  Aid  to. — 
Dr.  L.  Fischer 581 

*Diagnostico  de  la  Tuberculosis  en  la 
Ninez  por  Medio  de  las  Inocula- 
ciones  Cutaneas  de  la  Tuberculina 
Diluida.— Dr.    L.    Fischer 580 

♦Distribution  des  Idsions  tubercu- 
leuses  chez  les  b^bds  et  chez  les 
petits  enfants;  fitude  fond(Se  sur 
autopsies. — Dr.  M.  WoUstein 433 

Distribution  of  Tuberculous  Lesions 
in    Infants    and    young    Children, 
The;    A  Study  based  upon  Post- 
mortem    Examination. — Dr.     M. 
WoUstein 423 

*Enfants  des  tuberculeux,  Les. — 
Dr.  T.  Sachs 485 

*Enfants,  La  tuberculose  chez  les; 
Surtout  celle  des  glandes  lymphati- 
ques.— Dr.  T.  Shennan 377 

*Enfermadades,  Sarampion,  Tos  Fe- 
rina  ^  Influenza  con  la  tuberculo- 
sis, La  Relacion  de  las  Infecciosas. 
—Dr.  E.  P.  Copeland 383 

*Examen  obligatoire  dans  les  creches, 
^coles,  orphelinats,  etc. — Dr.  A. 
Baumel 607 

*Examen  Obligatorio  en  los  Plante- 
les,  Escuelas,  Asilos  de  Huerfanos, 
etc. — Dr.  A.  Baumel 607 


♦Examination  and  Treatment  in 
Nurseries,  Asylums,  etc.,  Com- 
pulsory.— Dr.  A.  Baumel 606 

Expectant  Treatment  of  Pulmonary 
l\iberculosis,  The,  A  contribution 
from   Orthopedic  Surgery  to  the 
Study  of  Tuberculosis. — Dr.  A.  B. 
Judson 676 


♦Familia,  Association  con  la;  Trans- 
micion  y  el  Progreso  de  la  Tuber- 
culosis en  los  Ninos  por  Medin  de 
la.— Dr.  C.  Floyd  y  Dr.  H.  I.  Bow- 
ditch 501 

♦Famille,  La  transmission  et  le  pro- 
gres  de  la  tuberculose  chez  les  en- 
fants par  les  rapports  dans  la. — 
Dr.  C.  Floyd  et  Dr.  H.  I.  Bow- 
ditch 502 

Family  Association,  A  Clinical  Study 
of  the  Transmission  and  Progress 
of  Tuberculosis  in  Children  through. 
—Dr.  C.  Floyd  and  Dr.  H.  I.  Bow- 
ditch 493 

Fetra,  Dr.  L.  E.  La. — Tuberculosis 
in  Infants 361 

Fife,  Dr.  C.  A. — Clinical  Manifesta- 
tions of  Tuberculous  Meningitis.  .  .   399 

Fischer,  Dr.  L. — An  Aid  to  the  Diag- 
nosis of  Tuberculosis  in  Infancy 
and  Childhood  by  Means  of  the 
Cutaneous  Inoculation  of  Diluted 
Tuberculin  or  Pure  Tuberculin.  .  .  .    581 

Floyd,  Dr.  C— A  Clinical  Study  of  the 
Transmission  and  Progress  of  Tu- 
berculosis in  Children  through 
Family  Association 493 

♦Frequence  de  la  tuberculose  chez 
les  enfants. — Dr.  C.  von  Pirquet.  .    566 

Frequency  of  Tuberculosis  in  Children 
— Dr.  C.  von  Pirquet 559 

Goodall,  Dr.  H.  S 512 

Green,  Dr.  E.  M. — Report  of  a  Case 
of  Miliary  Tuberculosis,  probably 
of  Bovine  Origin,  in  a  Child  aged 
Four  and  One-half  Months 394 

Hamill,  Dr 514 

♦Hilufigkeit  der  l\iberkulose  im 
Kindesalter. — Dr.  C.  von  Pirquet.  .    567 

Heiman,  Dr.  H.- — Clinical  Observa- 
tions on  the  von  Pirquet  Reaction 
in  Children 569 

♦Higienica  y  Climatologica,  La  Pro- 
filatis  de  la  Tuberculosis  en  la 
Ninez. — Dr.  F.  L.  Wachenheim ....   634 

Holt,  Dr.  L.  E. — A  Report  upon  One 
Thousand  Tuberculin  Tests  in 
young  Children 551 


INDEX   TO   VOLUME   II,    SECTION   IV. 


713 


PAGE 

Hutchinson,  Dr.  Woods. — The  Local- 
ization of  Tuberculosis  in  Chil- 
dren    417 

Discussion 512 

Hygiene  of  Mouth,  Nares,  Pharnyx, 
Intestine,  Skin,  Mucous  Membrane 
in  General;  of  Lymph  Bodies  and 
Lungs.  Prevention  of  Colds. — Dr. 
N.  P.  Barnes 671 

Hygienic  and  Climatic  Prophylaxis 
of  Tuberculosis  in  Children,  The. 
—Dr.  F.  L.  Wachenheim 023 

*Hygienische  und  klimatische  Pro- 
phylaxe  der  Tuberkulose  in  der 
Kindheit,  die. — Dr.  F.  L.  Wachen- 
heim    633 


*Infantil,  El  Contagio  humano  como 
factor  en  la  Tuberculosis. — Dr.  J. 
Comby 511 

Infantile,  Role  de  la  contagion 
humaine  dans  la  tuberculose. — 
Dr.  J.  Comby 503 

*Infantile  Tuberculosis,  Human  Con- 
tagion as  a  Factor  in. — Dr.  J. 
Comby 510 

Infants,  Tuberculosis  in. — Dr.  L.  E. 
La  Fetra 3G1 

*Infectionskranlcheiten  —  Masern, 
Keuchhustenund  Influenza,  zur  Tu- 
berkulose bei  Kindern,  die  Bezie- 
hungen  der.— Dr.  E.  P.  Copeland.  .   384 


Jacobi,    Dr.    Abraham. — President's 

Address 355 

Discussion 514 

Judson,  Dr.  A.  B. — The  Expectant 
Treatment  of  Pulmonary  Tubercu- 
losis: A  Contribution  from  Ortho- 
pedic Surgery  to  the  Study  of  Tu- 
berculosis    676 


♦Kindertuberkulose,  menschliche  An- 
steckung  aLs  ein  Factor  in. — Dr.  J. 
Comby 510 

♦Kinder  tuberkuloser  Eltern,  die. — 
Dr.  T.  Sachs 486 

*Kindern,  besonders  mit  Riicksicht 
auf  die  Lymphdriisen-Tuberkulose, 
Tuberkulose  bei. — Dr.  T.  Shennan  378 

*Kindern  tuberkuloser  Eltern,  das 
Vorkommen  der  Lungentuberku- 
lose  bei. — Dr.  J.  A.  Miller  und  Dr. 
I.  O.  Woodruff 492 

*Klinischen  Erscheinungen  der  tuber- 
kulosen  Gehirnhaut-Entziindung, 
die. — Dr.  D.  J.  McCarthy  und  Dr. 
C.  A.  Fife 414 


Knopf,  Dr.  S.  A. — Overcoming  the 
Predisposition  to  Tuberculosis  and 
the  danger  from  Infection  during 
Childhood 635 

Kotz,  Dr.  A.  L. — Report  of  a  Case  of 
Miliary  Tuberculosis,  probably  of 
Bovine  Origin,  in  a  Child  Aged 
Four  and  One-half  Months 394 


*Lait  de  femme;  sur  le  pouvoir  opso- 
nique  du.  Recherche  contre  le 
bacille  de  la  tuberculose. — Dr.  W.  J. 
Butler 393 

*Lecho  Humana  con  Relaci6n  al 
Bacilo  de  la  Tuberculosis,  Investi- 
gacion  del  Poder  Opsonico  de  la. — 
Dr.  W.  J.  Butler 393 

Libman,  Dr.  E 597 

Litchfield,  Dr.  Lawerence 415 

♦Localisation  primaire  de  la  tuber- 
culose chez  les  enfants.  La  Dr.  W. 
Hutchinson 422 

Localization  of  Tuberculo.sis  in  Chil- 
dren.— Dr.  W.  Hutcliinson 417 

*Lombaire  (piqutire)  dans  la  m^nin- 
gite  tuberculeuse  des  enfants,  Va- 
leur  diagnostique  de  la. — Dr.  F.  E. 
Sondern 595 

Lumbar  Puncture  in  Acute  Tuber- 
culous Meningitis  in  Children, 
Diagnostic  Value  of. — Dr.  F.  E. 
Sondern 588 

*Lumbarpunktion  in  acuter  tuberku- 
loser Meningitis  bei  Kindern,  der 
diagnostische   Wert    der. — Dr.    F. 

E.  Sondern 596 

♦Lumbar  (Puntura)  en  la  Meningitis 

Tuberculose  Aguda  de  los  Niiios, 
El  Valor  Diagnostico  de  la. — Dr. 

F.  E.  Sondern 595 


♦Manifestaciones  Clinicas  de  la  Men- 
ingitis Tuberculosa,  Las. — Dr.  D. 
J.  McCarthy  y  Dr.  C.  A.  Fife 412 

♦Manifestations  cliniques  de  Mcf^nin- 
gite  tuberculeuse. — Dr.  D.  J.  Mc- 
Carthy et  Dr.  C.  A.  Fife 413 

McCarthy,  Dr.  D.J. — Clinical  Manifes- 
tatioasof  IXiberculous  Meningitis.  .   399 

Measles,  Whooping-cough,  antl  In- 
fluenza, The  Relation  of,  to  Tuber- 
culosis in  Childhood. — Dr.  E.  P. 
Copeland 379 

Medin,  Prof.  O. — On  von  PirqueCs 
Cutaneous  Tuberculin  Test  on 
Children  in  the  First  Year  of  In- 
fancy     385 

Mecresufer,  die  Behandlung  am,  und 
in  der  freieu  Jjuf t  in  dem  Sea  Breeze 


714 


INDEX    TO   VOLUME    II,    SECTION   IV. 


PAGE 

Hospital  fiir  tuberkulose  Krank- 
heiten  der  Ivnochen,  Gelenke  und 
Driisen. — Dr.  J.  W.  Brannan 702 

*Mer,  Le  traitement  k  I'air  de  la,  et 
h  I'air  pur,  employ^  &,  I'hopital 
"Sea  Breeze,"  pour  les  cas  de  tu- 
berculose  des  os,  des  articulations 
et  des  glandes  chez  les  enfants. — 
Dr.  J.  W.  Brannan 701 

Meyer,  Dr.  Willy. — The  Possibility 
of  Avoiding  Conspicuous  Scar  For- 
mation in  Softened  Tuberculo- 
sis of  the  Cervical  Glands 703 

Miliary  Tuberculosis,  probably  of 
Bovine  Origin,  in  a  Child  Aged 
Four  and  a  Half  Months,  Report 
of  a  Case  of. — Dr.  E.  M.  Green  and 
Dr.  A.  L.  Kotz 394 

Miller,  Dr.  J.  A. — The  Occurrence  of 
Pulmonary  Tuberculosis  in  Children 
of  Tuberculous  Parents 487 

*Muttermilch  fiir  Tuberkelbazillen, 
Priifung  der  opsonischen  Kraft  der. 
—Dr.  W.  J.  Butler 393 


*Ninos,  con  Referencia,  en  Particular, 
A  la  Tuberculosis  de  las  Glandus 
Linfaticas,  Tuberculosis  en  los. — 
Dr.  T.  Shennan 376 

*Niiios  de  los  Tuberculosos,  Los. — Dr. 
T.  Sachs 485 

*Niiios  de  Padres  Tuberculosos,  Tu- 
berculosis Pulmonar  en  los. — Dr.  J. 
A.  Miller  y  Dr.  I.  O.  Woodruff 491 

*Niiios,  un  Analisis  de  130  Casos  en  el 
Hospital  con  Relacion  a  la  Etio- 
logia,  y  el  Diagnostico  la  Preven- 
cion  y  el  Tratamiento,  Tuberculosis 
en  los.— Dr.  L.  E.  La  Fetra         .  .   36G 


Obstructive  Abnormalities  of  the 
Nose  and  Throat.  Predisposing 
Factors  to  Tuberculosis  in  School 
Children. — Dr.  J.  J.  Cronin 515 

*Oftalmica,  Prueba,  de  Calmette  en 
los  Enfernedades  de  los  Nifios,  El 
Valor  de  la.— Dr.  E.  M.  Sill 546 

*Ophthalmique,  Reaction,  Sa  valeur 
pour  le  diagnostic  chez  les  nourris- 
sons  et  les  jeunes  enfants. — Dr. 
E.  M.  Sill 546 

*Ophthalmo-Reaktion  fiir  die  Diag- 
nose von  Krankheiten  bei  jungen 
Kindern,  der  Wert  und  die  Anwend- 
barkeit  von  Calmettes. — Dr.  E.  M. 
Sill 546 

*Orthopa,dischen  Chirurgie  zum  Stu- 
dium  der  Tuberkulose,  ein'  Beitrag 
aus  der. — Dr.  A.  B.  Judson 681 


*Orthop6dique  a  I'^tude  de  la  tuber- 
culose,  Une  contribution  de  la  chir- 
urgie.— Dr.  A.   B.  Judson 680 

Ortopedia  Quirurgica  al  Estudio  de 
la  Tuberculosis,  Contribucion  de  la. 
— Dr.  A.  B.  Judson 680 


Parks  and  Playgrounds,  Relation  of 
Tuberculosis  to. — Mr.  H.  Brad- 
street 619 

Parsons,  Mrs.  H.  G.— The  Value  of 
Children's  Gardens  in  Congested 
Neighborhoods  for  those  Children 
\Yith  a  tendency  to  Tuberculosis, 
or  for  those  in  whom  the  Disease  has 
been  Arrested  or  Cured 608 

P^hu,  M. — La  p^ritonite  tuberculeuse 
du  nourrisson 454 

Pericardium  in  Children,  Tuberculo- 
sis of  the.— Dr.  J.  S.  Wall 464 

P^ritonite  tuberculeuse  du  nourris- 
son, La.— M.  E.  Weill  et  M.  P^hu .  .   454 

von  Pirquet  Reaction  in  Children, 
Clinical  Observations  on  the. — Dr. 
n.  Heiman 569 

von  Pirquet,  la  Reacci6n  de  en  los 
Ninos,  Algunas  observaciones  Clfn- 
icas  Sobre. — Dr.  H.  Heiman 572 

*von  Pirquet,  la  reaction  de,  chez  les 
enfants,  Quelques  observations 
diniques  sur. — Dr.  H.  Heiman.  .  .  .    573 

*von  Pirquet'schen  Reaktion  bei  Kin- 
dern, einige  klinische  Beobachtun- 
gen  bei  der. — Dr.  H.  Heiman 573 

Pirquet,  Dr.  C.  v. — Frequency  of 
Tuberculosis  in  Children 559 

^Placenta,  Transmission  de  la  Tuber- 
culose  par  le. — Dr.  A.  S.  Warthin.  .    531 

*Placenta,  Transmision  de  la  Tuber- 
culosis por  Medio  de  la. — Dr.  A.  S. 
Warthin 529 

Placental  Transmission  of  Tuberculo- 
sis.—Dr.  A.  S.  Warthin 524 

*PIacentar-Ubertragung  der  Tuber- 
kulose, die.— Dr.  A.  S.  Warthin...   532 

Predisposition  to  Tuberculosis  and  the 
Dangers  from  Infection  during 
Childhood,  Overcoming  the. — Dr. 
S.  A.  Knopf 635 

Preservation  de  I'Enfance  contre  la 
tuberculose,  Oeuvre  de  la  Section 
Lyonnaise. — Dr.  Edmund  Weill.  .   648 

President's  Address. — Dr.  A.  Jacobi .  .   355 

^Prognose  der  Lungenschwindsucht 
bei  Kindern  unter  dem  fiinfzehnten 
Lebensjahre. — Dr.  F.  A.  Craig.  .  .  .   670 

*Prognosis  de  la  Tuberculosis  Pul- 
monar en  los  Niiios  Menores  que 
Quince  Afios.— Dr.  F.  A.  Craig 669 


INDEX   TO   VOLUME    II,    SECTION    IV. 


715 


Prognosis  in  Pulmonary  Tuberculo- 
sis in  Children  under  Fifteen  Years 
of  Age,  TJie.— Dr.  F.  A.  Craig.  ...   652 

*Pronostic  dans  la  tuberculose  pul- 
monaire  chez  les  enfants  audessous 
de  quinze  ans. — Dr.  F.  A.  Craig.  .  .   669 


Resolutionsvorschlag,     ein. — Dr.     A. 

Baumel 603 

Rey,  M.  A. — De  I'air  confin6  et  de  la 

tuberculose 534 

Hist,  Dr 512 


Sachs,  Dr.  T.— Children  of  the  Tuber- 
culous     479 

Scar  Formation  in  Softened  Tuber- 
culosis of  the  Cervical  Glands,  The 
Possibility  of  Avoiding  Conspicu- 
ous.— Dr.  W.  Meyer 703 

School  Children,  An  Expeditious  Me- 
thod for  the  Detection  of  Tubercu- 
losis among. — Dr.  H.  Shoemaker. .   589 

Schools,     Open-air. — Mrs.     A.      G. 
Spencer 612 

Seashore    and     Fresh-air    Treatment 
at    Sea    Breeze    Hospital. — Dr.    J. 
W.  Brannan 682 

Shaw,  Dr.  H.  L.  K.— The  Cutaneous 
and  Ophthalmic  Tuberculin  Tests 
in  Infants  under  Twelve  Months 
of  Age 547 

Shennan,  Dr.  T. — Tuberculosis  in 
Children 367 

Shoemaker,  Dr.  H. — An  Expeditious 
Method  for  the  Detection  of  Tu- 
berculosis among  School  Children.  .    598 

Sill,  Dr.  E.  M.— The  Value  and 
Reliability  of  Calmette's  Ophthal- 
mic Reaction  to  Tuberculin 542 

Sondern,  Dr.  F.  E. — Diagnostic  Value 
of  Lumbar  Puncture  in  Acute  Tu- 
berculous Meningitis  in  Children.  .    588 

Spencer,  Mrs.  A.  G.  —  Open-air 
Schools 612 


PAGE 

Teissier,  Dr.  J. — Des  albuminuries 
intermittentes  de  I'enfance  con- 
sider^s  dans  leurs  relations  avec 
I'h^redite  tuberculeuse 473 

Tubercuhn  Tests  in  Young  Children, 
A  Report  upon  One  Thousand. — 
Dr.  L.  E.  Holt 551 

*Tuberculose  milaire  chez  un  enfant 
de  4  mois  et  demi.  Rapport  de 
I'autopsie. — Dr.  E.  M.  Green  et  Dr. 
A.  L.  Kotz 397 

*Tuberculosis  miliaria  en  un  nino  de 
cuatro  meses  y  medio  de  edad. 
Informe  sobre  la  autopsia. — Dr. 
E.  M.  Green  y  Dr.  A.  L.  Kotz 398 


*Verteilung  tuberkuloser  Verletzun- 
gen  bei  Sauglingen  und  jungen 
Kindern,  die;  eine  Studie  auf 
Grund  von  Autopsien. — Dr.  M. 
WoUstein 432 

von  Pirquet's  Cutaneous  Tuberculin 
Test  in  Children  in  the  First  Year 
of  Infancy,  On.— Dr.  O.  Medin 385 


Wachenheim,  Dr.  F.  L.— The  Hy- 
gienic and  Climatic  Prophylaxis  of 
Tuberculosis  in  Childhood 623 

Wall,  Dr.  J.  S. — Tuberculosis  of  the 
Pericardium  in  Children 464 

Warthin,  Dr.  A.  S.— The  Placental 
Transmission  of  Tuberculosis 524 

Weill,  M.  E. — Oeuvre  de  la  preserva- 
tion  de   I'enfance  contre  la  tu- 
berculose.— Section  Lyonnaise.  .   648 
La     peritonite     tuberculeuse     du 
nourrisson 454 

White,  Dr.  C.  Y.— Tuberculous  Pul- 
monary Cavities  in  Infants 434 

Wollstein,  Dr.  M.— The  Distribution 
of  Tuberculous  Lesions  in  Infants 
and  young  Children 423 

Woodcock,  Dr.  H.  D 513 

Woodruff,  Dr.  I.  O. — The  Occurrence 
of  Pulmonary  Tuberculosis  in 
Children  of  Tuberculous  Parents.  .   487 


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Int ernat  i  ona  1  c  ongr  ■•  s  s   on 
TubercTilosie.   6th  Vrashington. 
V.2       Section  5-4  1908 


UiL 


